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

2. 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 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 improve the emergency management plan from lessons learned during the tabletop exercise Exercise Objectives

3. 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 (debriefing) is the final component of the exercise followed by an exercise evaluation.

4. 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. 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. 6 Hospital [Your institution] Certified beds – Staffed beds – Staff – FTEs ED visits – Airborne Infection Isolation Rooms – [Graphic of your facility]

7. 7 Module One Recognition

8. 8 [Season] in [Local area] Current weather – (December –April) Used to set the scene – (would suggest flu season) time of year etc. Graphics depicting local area e.g. Manhattan, Bronx, etc.

9. 9 [Day 1] at 11:00 am A 33-year-old man (David) arrives at the ED complaining of fever with chills, a persistent cough, body aches and loose stools. He complained of having the “stomach flu” for two days. He is triaged in the ED and returns to the waiting room for an hour before he is called back into an exam area. On exam his vital signs are temperature 101.2F, BP 96/50, HR 108, Oxygen saturation of 92% on room air, and RR 24 with crackles at the right base.

10. 10 [Day 1] at 3:00 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 10:00 pm.

11. 11 [Day 2] at 9:00 am The ED has approximately [12] people waiting to be seen for complaints of fever, cough and general malaise. They are between the ages of 21 and 35 years old. [Six] patients have already been admitted for community- acquired or atypical pneumonia since yesterday. The infection control team is not aware of the admissions.

12. 12 [Day 2] at 9:00 am David’s fiancé (Donna) is at the bedside and reports that she has had a cough, headache and myalgia for 7 days but has felt well enough to continue working. She is a nurse in the Medical ICU and has stopped by to visit.

13. 13 [Day 2] at 4:00 pm Donna is at the bedside of her fiancé and she has now developed worsening chills and a fever. She goes home to rest and will stop by to visit in the morning before she starts her day shift.

14. 14 [Day 3] at 7:00 am [Three] RNs (including Donna) and [2] Nursing Aides scheduled for the day shift in the Medical ICU call out sick. The [two] Respiratory Therapists that cover the Medical ICU call off sick. An Environmental Service employee for the day shift in the Medical ICU is complaining of chills and temperature. She decides to go home one hour after arriving at work.

15. 15 [Day 3] at 5:00 pm The ICU Nursing Director contacts the VP of Clinical Services for approval to call agency nurses [25%] of the staff have called out with flu like illness and [5] ICU patients have developed new onset fevers The VP of Clinical Services also receives a phone call from the Respiratory Therapy director [4] of the Respiratory Therapists have called out sick and they need to request help from a temporary agency

16. 16 [Day 3] at 9:00 pm David develops acute respiratory failure requiring intubation and mechanical ventilation. An infectious disease consultation is called. The on-call pulmonologists perform a bronchoscopy and a bronchial alveolar lavage at the bedside. All cultures and stains are nondiagnostic. His clinical status deteriorates and he expires at 7:45 pm. Donna has been admitted for atypical pneumonia.

17. 17 Situation Report #1 [Specify dates for Days 1-3] Total patients with flu-like/respiratory illness: Patients admitted[10] Seen In ED[25] Fatalities[1] # HCWs ill:[22] Total available beds by department: [8] Adult Medical/Surgery [3] Pediatric Medical/Surgery [1] ICU [2] Telemetry [6] Other

18. 18 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, bed, infection control, supply, and environmental needs at this point?

19. First Breakout Group Report Back

20. 20 Module Two Response

21. 21 [Day 3] at 11:00 pm Earlier this evening, the CDC learns that clusters of atypical pneumonia are being reported from southern China. The evening news is reporting the World Health Organization (WHO) teams are traveling to southern China to evaluate possible SARS-like illness.

22. 22 [Day 4] at 8:30 am The hospital Infection Control Practitioner (ICP) notifies the [Local DOH] this morning at 7 am about the 33-year-old male fatality and the unusual numbers of healthcare workers out with respiratory illness. The ICP also reports that David’s fiancé (Donna) is now admitted with the same symptoms. Donna recently visited China with her sister and returned eleven days ago. The ICP reports that several ill employees seem to have had prior contact with Donna.

23. 23 [Day 4] at 11:00 am The Department of Health Medical Epidemiologist comes to your facility to review cases and interview Donna. Blood and Nasopharyngeal swab specimens from David and Donna are split and sent to the Public Health Lab and CDC. Patients with a diagnosis of atypical, community acquired pneumonia or acute respiratory illnesses are placed on Isolation Precautions and specimens are obtained for testing.

24. 24 [DOH] Health Alert Issued Year] ALERT #38: Suspected Case of Severe Acute Respiratory Illness alert 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: A previously healthy 33-year-old woman who had visited China less than 11 days ago has developed an unidentified respiratory illness. Her previously healthy male partner has expired from a similar respiratory illness. The [Your City] DOH, and the federal Centers for Disease Control and Prevention (CDC) are currently conducting epidemiologic and laboratory investigations. The [your city] DOH 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 Asia or had contact with someone who has been to Asia or works as a healthcare worker. [Local DOH] requests immediate reporting of any cases with the above illness….

25. 25 [Day 4] at 3:30 pm The Vice President of Clinical Services reports that 10-20% of nursing personnel have called out sick for the night shift as have numerous house staff and physicians. [Four] patients who had recently been in Labor & Delivery are returning with complaints of fever and respiratory illness.

26. 26 Laboratory Results Preliminary testing at the Public Health Laboratory (ELISA and RT-PCR) on specimens from the 33-year-old male and his fiancé are found to be positive for the SARS coronavirus. CDC is now confirming SARS-CoV in specimens sent by the PHL for confirmation. [Day 4] at 9:00 pm [Day 5] at 9:00 am

27. 27 [Day 5] at 9:00 am Based on reports of suspected or confirmed SARS cases in [Your City] as well as in China and several other countries, the WHO and CDC issue an international health alert.

28. 28 Government Agency Responses Joint press conference is conducted with the Mayor, DOH and hospital Emergency Operation Center (EOC) activated. [DOH] initiates active surveillance and contact investigations citywide and at [your] hospital. The DOH assigns a senior medical epidemiologist as full time liaison to [your] hospital. Frequent mayoral and DOH press briefings to address public concerns. DOH maintains provider and public hotlines, and conducts daily conference calls with all city hospitals to provide updates on the outbreak DOH monitors hospital bed capacity and staffing/supply needs citywide

29. 29 Situation Report #2 [Specify dates for Days 1-5] Total Suspect and Confirmed SARS cases at your hospital: [43] patients admitted [4] in ED [8] admitted to ICU Total worried well in ED: [~65] Fatalities: [1] # of HCWs among SARS cases: [39] Total available beds by Department [0] Adult Medical/Surgery [0] Pediatric Med/Surgery [0] ICU [2] Other No other hospitals in the area have been affected

30. 30 Module Two Breakout Group Discussion How will you handle the increasing number of ill? Worried well? Where and how will you set up triage? How will you identify and handle exposed employees who are ill? Who are asymptomatic? Where will you house all the patients needing Airborne Infection Isolation Rooms? What supply and materials management issues will be critical to address?

31. Second Breakout Group Report Back

32. 32 Break

33. 33 Module Three Surge Capacity

34. 34 [Day 8] at 9:00 am (1 week later) [Three] employees, (1 nurse, 1 respiratory therapist and a resident) who assisted with the intubation of David are admitted to the ICU. All have acute respiratory distress syndrome and sepsis. The on-call pulmonologist who performed the bedside bronchoscopy on David has expired from respiratory distress syndrome. Several household members of infected HCWs are in the ED complaining of flu-like illness.

35. 35 [Day 8] at 10:00 am All AIIRs are full. There are no additional ICU beds and all ventilators are in use. Your hospital’s Emergency Department is on diversion (bypass) and filled with concerned individuals and persons with febrile illness.

36. 36 Epidemiologic Investigation Donna is recovering but 3 of her family contacts have developed febrile respiratory illness and two are hospitalized with pneumonia. Although many of the cases at [Your Hospital] were traced to either an exposure to David or Donna, 30% of healthcare worker cases were not. Case finding identified a patient who had been admitted with community acquired pneumonia two weeks ago and placed on Standard Precautions. He received several nebulizer treatments while hospitalized The patient was contacted at home and reported that he had traveled to China to visit his mother in the hospital.

37. 37 [Day 8] at Noon The local midday news on Channel [?] reports an increase in cases of acute respiratory illness with flu-like symptoms that are being seen in several clinics and other EDs in the city. EDs are particularly crowded today - there are reports that many hospital employees have become ill. [Your Facility’s] phone lines are jammed with people calling for information and to make clinic appointments for tomorrow AM. Callers are becoming irate at the long phone wait times to speak with hospital personnel about their concerns.

38. 38 [Day 8] at 3:00 pm The numbers of healthcare providers reporting in sick and those seeking care from other area hospitals is increasing. Major local and national news channels are running continuous coverage of the events. Subject matter experts are speculating that this outbreak of SARS may be worse than Toronto 2003.

39. 39 [Day 8] at 4:00 pm Area hospitals, clinics and doctors’ offices are reporting a large influx of patients throughout the day who are convinced that they have been exposed to SARS. Other people, who are extremely ill, are refusing to go to the hospital as they are convinced that most exposures occur there. They quote the Toronto experience. Daycare providers and schools are receiving calls from parents who are concerned about letting children of health care workers from affected hospitals attend classes.

40. 40 [Day 9] at 9:00 am There have been 3 more fatalities related to SARS at your hospital. Attention is focusing on planning for the possibility of increased fatalities, in the event that hospital morgues become full.

41. 41 Situation Report #3 [Specify dates for Days 1-9] Total suspect and confirmed SARS cases at your facility: [#] patients admitted [#] in ED Total worried well in ED: [~#] # of HCWs among SARS cases: [#] Fatalities: [#] Total available beds by Department [#] Adult Medical/Surgery [#] Pediatric Med/Surgery [#] ICU [#] Other

42. 42 Module Three Group Discussion How does your Emergency Response Plan address the need for surge capacity? How are conducting screening at facility entrances? How are you communicating with staff, patients, and families? What type of support are you providing for staff being isolated/quarantined at home? How are you dealing with staff fatigue? Mental health issues? What might you have done differently earlier in the outbreak?

43. 43 Hot Wash What have you learned during this tabletop exercise? What are the hospital’s Emergency Preparedness strengths? What are the weaknesses / gaps of 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.

44. 44 Thank you!