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 management 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 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 (hot/cold) Used to set the scene – time of year etc. Graphics depicting local area e.g. Manhattan, Bronx, etc.

9. 9 [Day One] 8:00 am in the ED Call from [Local DOH] [Local DOH] has noted an increase in reports of respiratory illness and fever at several nearby hospitals over past 24 hours [Local DOH] requests: Report any unusual activity Lower testing threshold for diagnostic testing

10. 10 [Day One] 9:00 am in the ED Status report from the charge nurse: [75] patients seen in ED in the last 24 hours [61] adults, [14] children Adult admissions in the last 24 hours Fever / respiratory[3] Trauma[3] Smoke inhalation[1] [One] pediatric admission with pneumonia Total of [three] patients admitted with a more severe fever and respiratory syndrome

11. 11 Patient 1 Medical History 55 year old male; [Your city] resident Investment banker with frequent international travel Alert, oriented, anxious, moderate respiratory distress No significant medical history Two-day history of shortness of breath T=101.2 o F, P=90, R=28, BP=180/100 O 2 Sat = 84%

12. 12 Patient 1 Medical History (continued). CXR showed a questionable LLL infiltrate. Blood cultures were negative. Shortly after admission yesterday, his status rapidly declined. During intubation in his hospital room, he goes into cardiac arrest and expires. Referred to medical examiner for autopsy.

13. 13 Patient 2 Medical History 21 year old female [Local] resident Alert, oriented, coughing frequently Chief complaint: “I’m burning up, and its hard to breathe” 1 pack/day smoker Two beers/day No other medical history

14. 14 Patient 2 Medical History ( continued) On admission, T=104 o F, P=120, RR=26, BP=90/60, O 2 Sat = 90% CXR is clear Blood cultures are negative

15. 15 Patient 3 Medical History Five year old male Lethargic, responsive to stimuli Mother states: “I can’t get his fever down!” Awaiting admission for pneumonia Both parents are present Father is coughing, but states he has “smoker’s cough” T=103 o F, HR=120, RR=30, BP=90/60, O 2 Sat = 80%

16. 16 [Day One] 9:00 am in the ED Since 7:00 AM, [Five] additional adults have now presented to the ED with fever and persistent cough A family of [four] with fever and shortness of breath are being referred to the ED from a nearby primary care center ED waiting area is full; many of the patients are febrile and coughing.

17. 17 [Day One] 10:00 am in the ED Two of the adults referred from the Primary Care Clinic are deteriorating with worsening respiratory status They are intubated and admitted to critical care; however there are currently no ICU beds available.

18. 18 [Day One] 10:00 am in the ICU 21-year-old female from yesterday deteriorates rapidly and requires ICU admission 5-year-old male is intubated and remains febrile

19. 19 [Day One] 11:00 am on CNN Headline News The CDC learns that clusters of severe respiratory illness and atypical pneumonia are being reported from Vietnam and surrounding countries The morning news is reporting that World Health Organization (WHO) teams are traveling to Vietnam to evaluate possible SARS-like illness however the causative agent has not yet been identified. There is strong evidence of human-to-human transmission

20. 20 Situation Report #1 Day 1 Patients with flu-like/respiratory illness: Patients admitted[8] In ED[32] Total worried well in ED [~40] Fatalities [2] Total available beds by department: Adult Medical/Surgery[8] Pediatric Medical/Surgery[3] ICU[0] Other[5]

21. 21 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. What are your infection control, supply, and environmental needs at this point? How will your hospital meet the current demand for ICU-level care (beds, staffing, supplies, etc.)?

22. First Breakout Group Report Back

23. 23 Module Two Response

24. 24 [Day One] 4:00 pm in the ED [40] patients with fever and cough were seen during the day shift. One of the patients is an off-duty ED nurse Respiratory hygiene and cough etiquette are sporadically enforced by busy ED staff. Rumors are circulating throughout the facility of a flu or SARS outbreak

25. 25 [Day One] at 8:00 pm [Your City] DOH has received a report from the Boston Department of Health A patient in the Boston City Hospital is suspected to have H5N1 influenza based on travel history and rapid antigen testing This patient had flown from Hanoi through [your local airport] to Boston on [Day One minus three].Several of the patient’s traveling companions reside in [Your City]. The current cluster of acute respiratory illness in Vietnam includes Hanoi The [Your City] DOH is sending a medical epidemiologist to [your hospital] to review cases and interview ill patients

26. 26 [Day One] 10:00 pm The Boston case had flown on Asian Air Flight 81 from Hanoi to [your city] [22] passengers from [your city] were on Flight 81. [Local DOH] and CDC are doing contact tracing for [your city] passengers. At least [eight] have been seen at [your hospital] since [Day One minus One].

27. 27 [Local Health Department] [2005] ALERT #38: Investigation of Suspected H5N1 Avian Influenza in a passenger from Vietnam to [local airport] on [Day One minus three]. [Local DOH] and CDC are currently conducting interviews of all persons who were on Asian Air Flight 81 traveling from Hanoi to [local airport] on [Day One minus three]. CDC & WHO report clusters of severe respiratory illness in Vietnam and surrounding regions. [Local DOH] requests immediate reporting of similar cases Please Distribute to All Medical, Pediatric, Family Practice, Laboratory, Critical Care, Pulmonary, Employee Health, and Pharmacy Staff in Your Hospital Dear Colleagues: The [Local DOH] is currently conducting interviews of all persons who were on Flight 81 from Hanoi, Vietnam to [your city] on [Day one minus three]. A 24-year old Vietnamese man on the flight is currently hospitalized in Boston with a severe respiratory illness. Danang, the town that he is from in Vietnam has been identified as one that is experiencing an outbreak with person-to-person transmission of a severe respiratory illness. The CDC/WHO recommends Airborne and Contact Isolation precautions until laboratory confirmatory of the causative agent is available. [Day Two] 9:00 am Health Alert

28. 28 Summary of Public Health and Other Governmental Agency Responses The Emergency Operations Center (EOC) is activated. A joint press conference is conducted with the Mayor, [Local DOH], CDC and [your hospital] [DOH] initiates active surveillance and contact investigations citywide and at affected hospital. The DOH assigns a senior staff medical epidemiologist to be a full time liaison to all affected hospitals, including [your hospital]. The DOH maintains a provider and public hotline, and conducts daily citywide hospital conference calls to provide clinical and epidemiological updates.

29. 29 [Day Two] Staff Concerns Press broadcasts about an outbreak of severe respiratory illness in [your city] are widespread. The ED and ICU staff are concerned that they have been exposed to an infectious disease. Several family members of the patients admitted yesterday are now coughing Rumors continue to circulate around the hospital The number of healthcare workers calling in sick is somewhat higher than normal.

30. 30 CDC: Phase 1 Pandemic Influenza The CDC confirms that H5N1 influenza has been identified in Vietnam, and surrounding countries in Asia. Person-to-person transmission has been documented The Boston index case from Asian Air Flight 81 tests positive for H5N1 influenza as well An H5N1 vaccine will not be available for 3-4 months

31. 31 CDC: Phase 1 Pandemic Influenza Personal Protective Measures recommended by CDC include: Airborne, Contact and Standard Precautions (N95 respirators for health care workers) Mask symptomatic patients until they can be isolated Oseltamivir is recommended for treatment of severe cases

32. 32 [Day Three] [Local DOH] medical epidemiologists are engaged in active contact tracing at [Your hospital] The ED currently has [17] patients waiting to be admitted with cough and fever 1/3 of staff have failed to report to work due to illness or fear of contracting influenza. Other hospitals in [Your City] are now reporting similar outbreaks

33. 33 Situation Report #2 [Specify dates for Days 1-3] Total confirmed and suspected cases of influenza: [43] patients admitted [17] in ED awaiting admission Total worried well in ED: [~75] Fatalities: [4] Total available beds by Department [0] Adult Medical/Surgery [0] Pediatric Med/Surgery [0] ICU [2] Other

34. 34 Module Two Breakout Group Discussion How will you handle the increasing number of ill? Worried well? Where and how will you set up triage? Where will you admit all the patients needing isolation? 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? What are your communication needs?

35. Second Breakout Group Report Back

36. 36 Break

37. 37 Module Three Surge Capacity

38. 38 [Day Four] at 10:30 am Many patients with non-specific complaints and without fever are seeking medical attention. Wait time in the ED for non-emergent patients is exceeding [18] hours. The number of patients waiting to be seen exceeds hospital capacity. EMS is also extremely busy.

39. 39 [Day Four] at 2:00 pm All major local and national news networks are broadcasting pandemic updates around-the-clock The death toll is starting to rise “TV Experts” compare this outbreak to the Spanish Flu in 1918. Media broadcasts of potential shortages of antivirals have resulted in long lines of people standing outside drug stores.

40. 40 [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. Patients are becoming impatient and starting to panic. They are desperate for treatment, antiviral prophylaxis or vaccine and are becoming 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.

41. 41 [Day Ten] There have been 3 more pediatric fatalities due to avian flu at your hospital. Attention is focusing on planning for the possibility of increased fatalities, in the event that hospital morgues and funeral parlors become full.

42. 42 Situation Report #3 [Specify dates for Days 1-10] Total suspect or confirmed influenza cases: [#] patients admitted [#] in ED Total worried well in ED: [~#] Fatalities: [#] Total available beds by Department [#] Adult Medical/Surgery [#] Pediatric Med/Surgery [#] ICU [#] Other

43. 43 Government Agency Responses The governor has requested resources from the Federal Government. The National Disaster Medical System has been activated. [DOH] is maintaining a provider and public hotline, and continuing its active 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 and minimize impact of the worried well on hospitals.

44. 44 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)?

45. 45 Hot Wash What have you learned during this tabletop exercise? What are the hospital’s Emergency Management Plan 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.

46. 46 Thank you!