Hospital Name Bioevent Tabletop Exercise Moderated by: and Facilitated by:

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Hospital Name Bioevent Tabletop
ExerciseModerated byandFacilitated by
Hospital Logo
Local Health Department Logo
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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 improve the emergency management plan
  from lessons learned during the tabletop exercise

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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.

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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

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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 its
  a tool and not the primary focus

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HospitalYour institution

• Certified beds
• Staffed beds
• Staff FTEs
• ED visits
• Airborne Infection Isolation Rooms

Graphic of your facility
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Module OneRecognition

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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.

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Day 1 at 1100 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.

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Day 1 at 300 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 patients inpatient bed does not become
  available until almost 1000 pm.

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Day 2 at 900 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.
•  

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Day 2 at 900 am

• Davids 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.

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Day 2 at 400 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.

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Day 3 at 700 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.

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Day 3 at 500 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

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Day 3 at 900 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
• 745 pm.
• Donna has been admitted for atypical pneumonia.

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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

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Module OneBreakout 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?

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First Breakout GroupReport Back
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Module TwoResponse

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Day 3 at 1100 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.

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Day 4 at 830 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 Davids 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.

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Day 4 at 1100 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.

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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.
•  

 
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Day 4 at 330 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.

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Laboratory Results
Day 4 at 900 pm

• 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 5 at 900 am
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Day 5 at 900 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.

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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

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Situation Report 2Specify 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

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Module TwoBreakout 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?

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Second Breakout GroupReport Back
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Break
Fifteen Minutes Please
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Module ThreeSurge Capacity

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Day 8 at 900 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.

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Day 8 at 1000 am

• All AIIRs are full.
• There are no additional ICU beds and all
  ventilators are in use.
• Your hospitals Emergency Department is on
  diversion (bypass) and filled with concerned
  individuals and persons with febrile illness.

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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.

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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 Facilitys 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.

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Day 8 at 300 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.

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Day 8 at 400 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.

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Day 9 at 900 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.

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Situation Report 3Specify 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

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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?

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Hot Wash

• What have you learned during this tabletop
  exercise?
• What are the hospitals Emergency Preparedness
  strengths?
• What are the weaknesses / gaps of the Emergency
  Preparedness Plan?
• What should the hospitals next steps in
  preparedness be?
• List and prioritize five short and long-term
  actions for follow-up.

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• Thank you!