California Emergency Medical Services Authority California Primary Care Association California Assoc

1

California Emergency Medical
Services Authority ? California Primary Care
Association
California Association of Health Facilities ?
California Hospital Association
2009 Statewide Medical and Health Exercise
Pandemic Influenza
Phase 3
Facilitated Tabletop Exercise
2
Todays Goals

• Identify partners in local health department
  jurisdiction active in planning for pandemic
  influenza
• Identify the roles, responsibilities and
  resources within the jurisdiction for responding
  to a pandemic influenza
• Develop the planning structure, identify
  participants and organize timeline for the 2009
  Statewide Medical and Health Exercise

3

California Emergency Medical
Services Authority ? California Primary Care
Association
California Association of Health Facilities ?
California Hospital Association
2009 Statewide Medical and Health Exercise
Pandemic Influenza
Module 1 Welcome, Background Introductions
4
Exercise Participants

• Local Health Department/HPP Entity
• HPP Partnership
• Hospitals
• Clinics
• Long Term Care Facilities
• EMS Agency and EMS Providers

• Law Enforcement
• Medical Examiner / Coroner
• EMS Providers
• Healthcare Practitioners
• Community Organizations

5
2009 Statewide Medical and Health Exercise
Pandemic Influenza

• 4 Phased approach

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Phase 1 Satellite Broadcast

• The purpose of the satellite broadcast, Expanding
  the Continuum of Care during a Pandemic Influenza
  Surge, was to strengthen the understanding of
  healthcare assets within a local community and to
  better understand the Continuum of Care and the
  need for assistance beyond the existing
  healthcare assets during a pandemic influenza
  surge
• Local Health Departments and Local Hospital
  Preparedness Program Entities invited local
  healthcare delivery response partners to
  participate 

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Objectives of the Satellite Broadcast

• Identify the types of healthcare delivery systems
  within the Continuum of Care, including their
  expected role, assets, and challenges related to
  a pandemic influenza surge
• Identify strategies used at the local level to
  promote community planning across the Continuum
  of Care, as demonstrated by real-world examples
  related to resource identification and
  allocation, communication, and patient movement
  within the Operational Area
• Discuss the various participant roles in
  promoting interagency collaboration across the
  Continuum of Care to optimally manage a pandemic
  influenza surge

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Phase 2 Gap Analysis

• Gap Analysis used to determine level of
  preparedness for each organization, including
• Identifying gaps in organizational planning
• Identifying resource needs
• Promoting interoperability in planning and
  response

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Structure of the Gap Analysis Instrument

• Tasks grouped into the phases of comprehensive
  emergency management
• Organized by discipline and/or type of facility
• Focused on roles, responsibilities and resources
• Used to aid in discussions to evaluate the level
  of preparedness within the community (not scored)

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Gap Analysis Participants

• Local Health Department/Local HPP Entity
• Local HPP Entity Partners (Continuum of Care)
• Hospitals
• Clinics
• Long Term Care Facilities
• EMS Agency and EMS Providers
• Other Members of Local Partnerships
• Law Enforcement
• Medical Examiner / Coroner
• Community Organizations

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Phase 3 Tabletop Exercise Objectives

• Build on the Satellite Broadcast and Gap Analysis
  to understand how patients will move through the
  Continuum of Care
• Provide opportunity for discussion to share
  strengths, identify gaps, and promote
  interoperability
• Provide foundation for local planning for the
  June 2009 Functional Exercise including
• Identify areas for improvement prior to
  functional exercise
• Develop exercise objectives

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Phase 4 Functional Exercise on June 18, 2009

• Final phase will be built on the Broadcast, Gap
  Analysis and Tabletop Exercise
• Functional Exercise is consistent with Homeland
  Security Exercise and Evaluation Program (HSEEP)
  requirements
• Incorporates Target Capabilities List (TCL)
  elements
• Addresses healthcare specific emergency
  management requirements
• Allows Hospitals to meet The Joint Commission
  exercise requirements

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California Emergency Medical
Services Authority ? California Primary Care
Association
California Association of Health Facilities ?
California Hospital Association
2009 Statewide Medical and Health Exercise
Pandemic Influenza
Module 2 Homeland Security Exercise and
Evaluation Program
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Homeland Security Exercise and Evaluation Program
(HSEEP)

• Provides a national standard for the development
  and conduct of exercises
• Part of the U.S. Federal Emergency Management
  Agencys National Preparedness Directorate under
  the Department of Homeland Security

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Homeland Security Exercise and Evaluation Program

• Capabilities-based exercise program that provides
  a standardized methodology and consistent
  terminology for designing, developing,
  conducting, and evaluating all exercises
• Provides tools and resources to help build
  self-sustaining exercise programs
• Includes a cycle, mix, and range of exercise
  activities of varying degrees of complexity and
  interaction
• Meets the National Incident Management System
  (NIMS) and the National Response Plan (NRP),
  National Response Framework, doctrine and
  protocols

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National Planning Scenarios

• Scenario 1 Nuclear Detonation 10-Kiloton
  Improvised Nuclear Device
• Scenario 2 Biological Attack Aerosol Anthrax
• Scenario 3 Biological Disease Outbreak
  Pandemic Influenza
• Scenario 4 Biological Attack Plague
• Scenario 5 Chemical Attack Blister Agent
• Scenario 6 Chemical Attack Toxic Industrial
  Chemicals
• Scenario 7 Chemical Attack Nerve Agent
• Scenario 8 Chemical Attack Chlorine Tank
  Explosion
• Scenario 9 Natural Disaster Major Earthquake
• Scenario 10 Natural Disaster Major Hurricane
• Scenario 11 Radiological Attack Radiological
  Dispersal Devices
• Scenario 12 Explosives Attack Bombing Using
  Improvised Explosive Devices
• Scenario 13 Biological Attack Food
  Contamination
• Scenario 14 Biological Attack Foreign Animal
  Disease (Foot and Mouth Disease)
• Scenario 15 Cyber Attack

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Target Capabilities List

• Facilitates capabilities-based planning
• Tasks are organized into 37 capabilities
• Provides a guide for developing a national
  network of capabilities that will be available
  when and where they are needed to prevent,
  protect against, respond to, and recover from
  major events
• Promotes common, shared planning

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Target Capabilities List

• Further developed into Activities and Tasks to
  meet the Target Capability
• Allows for assessment and analysis of level of
  preparedness
• Provides a defined metric for entities to
  determine their current state of readiness
• Provides a goal to achieve in preparedness
  planning

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Target Capabilities Identified for 2009 Statewide
Exercise

• The following Target Capabilities have been
  defined for the Tabletop and Functional Statewide
  Exercise
• Interoperable Communications
• Intelligence / Information Sharing and
  Dissemination
• Medical Surge (Patient movement through the
  Continuum of Care)

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Capabilities, Activities and Tasks

• Target Capability Communications
• Activity Alert and Dispatch
• Task ComC 4.2 Implement response communications
  interoperability plans and protocols
• Target Capability Intelligence/Information
  Sharing and Dissemination
• Activity Incorporate All Stakeholders Into
  Information Flow
• Task ComC 1.1.1 Identify all Federal, State,
  Tribal, and local law enforcement agencies to be
  included in the information sharing framework

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Capabilities, Activities and Tasks

• Target Capability Medical Surge
• Activity Incident Management
• Task Res.C1b 4.1 Activate healthcare system
  incident command
• Activity Implement Surge Patient Transfer
  Procedures
• Definition Transition from pre-event bed
  utilization to access surge capabilities
• Task Res.C1b 5.2 Activate alternative care
  sites and overflow emergency medical care
  facilities to manage hospital surge capacity
• Note this Capability also meets Joint
  Commission Standard EM.02.01.01 Element 6

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Questions?

• Homeland Security Exercise and Evaluation web
  site
• https//hseep.dhs.gov

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California Emergency Medical
Services Authority ? California Primary Care
Association ?
California Association of Health
Facilities ? California Hospital Association
2009 Statewide Medical and Health Exercise
Pandemic Influenza
Module 3 Pandemic Influenza Information
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Historical Perspective of Pandemic Influenza

• Worldwide pandemics of influenza occur when a
  novel virus emerges to which the population has
  little immunity
• The 20th century saw three such pandemics
• Most notable 1918 Spanish influenza pandemic
• Responsible for 20 million deaths
• Risk of another pandemic arising from the current
  epidemic of avian influenza

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Strains of the Virus

• Strains of avian influenza interact with human
  influenza
• a mutation can occur, creating a virus capable
  of human-to human transmission, initiating a
  pandemic.

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Predicting the Severity of a Pandemic

• The impact of a pandemic cannot be predicted
  precisely
• Will be affected by
• Virulence of the virus
• How rapidly it spreads
• Availability of vaccines and antiviral
  medications
• Effectiveness of pharmaceutical and
  non-pharmaceutical community containment measures

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Expected Impact in California

• 25 to 35 of the population may become ill and
  nearly 200,000 Californians may die
• Impact of the pandemic could last for as long as
  18 months, with waves of activity
• Non-pharmaceutical containment measures are key
  to controlling the spread of virus
• Vaccination and antiviral treatment are
  anticipated to be the most effective
  pharmaceutical strategies
• effective vaccines or antiviral medications may
  be delayed or in limited supply

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Impact in California (contd)

• Real concern for fear and panic among the public
  as well as the response community
• Will there be enough staff? Supplies? Equipment?
  Vaccine? Medicines?
• Ability of Federal government to support the
  response in California will be limited at the
  onset
• Virus will be widespread and not limited to one
  jurisdiction, region or state

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Planning Partnerships

• Impact of the pandemic will cross all disciplines
• Will lead to disruption in service
• Direct impact of staff due to illness and death
• Indirect impact of employees caring for ill
  family members
• Indirect impact when daily services (schools,
  child care, adult day care, transportation) are
  disrupted
• Demonstrates the need for sharing of planning and
  response assumptions

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WHO Pandemic Phases
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Pandemic Flu Phases

• The World Health Organization defines 6 phases of
  a pandemic
• Interpandemic Period
• Phase 1 no new virus subtypes in humans
• Phase 2 no new virus in humans, but animal
  virus poses risk of human transmission
• Pandemic Period
• Phase 3 humans infected with novel virus but
  no human-to-human transmission has occurred

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Pandemic Flu Phases

• The World Health Organization defines 6 phases of
  a pandemic
• Pandemic Period
• Phase 4 small clusters of cases with
  human-to- human transmission spread is highly
  localized
• Phase 5 large clusters appear, but
  human-to- human transmission is still localized
  risk of pandemic is substantial
• Phase 6 Increased and sustained transmission
  is documented in the general population

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For More Information

• U.S. Government Pandemic influenza Website
• www.Pandemicflu.gov
• World Health Organization
• www.WHO.org
• Centers for Disease Research and Policy (CIDRAP)
• http//www.cidrap.umn.edu/

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California Emergency Medical
Services Authority ? California Primary Care
Association
California Association of Health
Facilities ? California Hospital Association
2009 Statewide Medical and Health Exercise
Pandemic Influenza
Module 4 Pandemic Influenza Tabletop Exercise
35
Tabletop Exercise Objectives

• Objectives
• Identify and clarify the authorities,
  responsibilities and roles of participating
  agencies in an integrated, comprehensive response
  to an influenza pandemic
• Demonstrate and outline the communication
  pathways and flow of information during a
  pandemic

36
Tabletop Exercise Objectives

• Objectives (continued)
• Plan for the projected need for increased medical
  capacity and capability in response to a patient
  surge
• Identify how patients will move through the
  Continuum of Care (home health, emergency medical
  services, healthcare facility expansions, and
  government authorized alternate care sites)
• Identify human and material resources and gaps
• Identify patient movement issues and strategies

37
Tabletop Exercise Objectives

• Objectives (continued)
• Plan for the prioritization and use of available
  resources and assets for maximum effectiveness
• Determine the procedures and processes for
  requesting assistance from levels of government

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Scenario- Novel Virus in Other Countries

• The H5N2 avian influenza virus that has been
  circulating in Asia for some time continues to
  infect a few humans, some with very limited
  contact with wild fowl or infected domestic
  poultry
• Recent unconfirmed media reports indicate higher
  human infection levels
• Ministries of Health are reported to be
  increasing surveillance in target communities and
  to verify reports

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Scenario Pandemic Influenza

• In January 2009, an outbreak of respiratory
  illness is reported in a Southeast Asian country
• At least 159 cases in one town are reported
• All age groups are affected
• 46 have been hospitalized
• 16 died from severe pneumonia and respiratory
  failure
• WHO confirms the outbreak and testing is pending
• Surveillance in surrounding areas increases and
  additional cases are identified throughout the
  country
• A case definition is being developed by WHO

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Scenario Pandemic Influenza

• January 16, 2009
• Viral cultures from initial victims are positive
  for type A influenza virus
• WHO affirms the isolates are H5N2
• Gene sequencing indicate avian in origin
• Viral antigenic and sequence analysis show the
  virus is different than previously circulating in
  poultry that caused human infections

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Scenario Pandemic Influenza

• January 30, 2009
• Neighboring countries report outbreaks of
  respiratory illness
• Once the virus epidemiology is available, WHO
  will update the public health guidelines
• The media headlines the novel virus, and it is
  the lead story on all major news networks and
  newspapers
• WHO Declares Pandemic Phase 6.

42
Scenario Pandemic Influenza Evolves

• With the pandemic declared, it is a matter of
  time before it reaches the U.S. and our
  communities
• The local health department, in conjunction with
  emergency management officials and the local
  government, convenes an emergency planning
  meeting of all key emergency and health care
  personnel

43
Small Break Out Groups by Sector

• Health Care
• Hospitals
• Public Health
• Clinics
• Long Term Care
• EMS Agencies and EMS Providers
• Emergency Management and Public Safety
• Local Office of Emergency Services
• Law Enforcement
• Medical Examiner/Coroner
• Community Organizations

44
Set Up for Small Break Out Group Discussions

• Introduce yourselves
• Name
• Organization Name
• Before you begin
• Appoint a facilitator/leader of the discussion
• Appoint a recorder
• Appoint a reporter

45
Break Out Discussion Points

• Introduce Your organization to the break out
  group
• What is the core mission of Your organization?
• What is the primary response role of Your
  organization during a pandemic influenza?
• Does Your organization have a pandemic influenza
  response plan or an annex to your emergency plan?
• What is Your biggest challenge to preparing for a
  pandemic?

46
Break Out Discussion Points

• What is the structure for leadership management
  and coordination (command and control structure)
  in your organization?
• How are the responsibilities for decision-making
  determined?
• Would you activate your command and control
  structure in your organization at this stage?
• How does your structure integrate with the local
  health department and emergency management?
• What is the primary role and responsibility of
  your organization at this stage in the pandemic?

47
Break Out Discussion Points

• Communications
• How would you be notified of this event?
• Are you connected to the California Health Alert
  Network (CAHAN)?
• What communication systems/technology are in use
  in your organization for internal and external
  communications?
• What agency would notify you or would you contact
  for information and guidance?
• How does your organization integrate into the
  Joint Information Center (JIC) in your county?

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Break Out Report

• Report Out on
• Small Group Discussions

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Pandemic Influenza Tabletop

• Next Step Full Group Discussion

50
The Scenario Evolves

• By mid February, outbreaks appear in China,
  Singapore, the Republic of Korea and Japan
• WHO reports
• Cases in all age groups but young adults most
  affected
• Case fatality is nearly 5
• Transmission, epidemiology, and virology of the
  novel virus is being investigated
• Public anxiety is high
• International travel is rapidly decreasing
• There is no vaccine available currently but
  production may begin within a month

51
The Scenario Evolves

• The Centers for Disease Control and Prevention is
  investigating a cluster of influenza-like-illness
  in New Jersey
• Index case is a 26 year old female who traveled
  to an affected country
• Admitted two days after symptom onset
• Died within 7 days with pneumonia and severe
  respiratory failure
• Nine other potential cases identified in
  neighbors, church and family members
• All cases and contacts are treated with
  antivirals and are under self-isolation

52
The Scenario Evolves

• CDC confirms all cases with Type A influenza and
  subtyping confirms H5N2
• Projected Case Fatality Ratio of 4-5
• CDC releases a Health Alert and urges public
  health departments to
• Increase surveillance for respiratory illness
  immediately
• Enhance public education and information
• Encourage medical and health providers to report
  cases and test suspicious cases

53
Scenario Other CDC Recommendations

• Strict Isolation of laboratory confirmed infected
  persons
• Quarantine of close contacts
• Educate the public on hand hygiene, respiratory
  hygiene, physical barriers, and other prevention
  measures to limit the exposure and risk of
  transmission
• Implement non-pharmaceutical community
  containment measures
• Increase social distancing by restricting public
  events and mass gatherings
• Use of masks by the public when in high risk for
  exposure gatherings or settings

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Scenario Impact on Healthcare

• Media reports spur an increase in calls to local
  health authorities, advice hot lines, emergency
  departments and 911 Dispatch
• Questions and inquiries include
• Where to go to be evaluated for the flu?
• What are the signs and symptoms of a pandemic
  flu?
• Will over the counter medicines work to treat
  this type of flu?
• Should children stay home from school?

55
Scenario Impact on Healthcare

• Emergency departments, urgent care centers and
  clinics report an increase in persons presenting
  with requests for flu shots
• Patients are asking for prescriptions of
  antibiotics and antiviral medications just in
  case flu symptoms appear
• Staff at some health care facilities are hoarding
  surgical masks and other personal protective
  equipment

56
Scenario Recommendations from CDPH

• The State Health Officer from California
  Department of Public Health issues a Health
  Alert
• Confirming there are no cases of H5N2 currently
  in California
• Local public health, healthcare, and response
  partners should prepare for outbreaks in their
  communities
• Supporting CDC recommendations, including those
  for surveillance of possible cases, educational
  outreach, and reporting and testing of suspicious
  cases.

57
Tabletop Discussion

• What are the three top critical issues and
  challenges for each discipline/responder at this
  point in the pandemic?
• Local Public Health
• Hospitals
• Clinics
• Long Term Care
• EMS
• Law Enforcement/Medical Examiner
• Emergency Management
• Community-based organizations
• Others

58
Tabletop Discussion Intelligence and
Information Sharing/Dissemination

• Who are your key local/community contacts and
  partners to share and obtain information?
• Do you have your key local partner agency contact
  names and numbers
• How does information flow of information among
  partner agencies and responders in your county?
• Sharing information about your organizations
  situational status
• Obtaining and updating information on the current
  pandemic situation
• How will the organizations prevent, report and
  address rumors or inappropriate information?

59
Tabletop Discussion Intelligence and
Information Sharing/Dissemination

• Describe the technologies that would be used to
  gather and disseminate information in your
  community?
• What information would you share with your
  organizations staff / employees?
• How would guidance on infection control, personal
  protective equipment and surveillance be
  disseminated to staff?

60
Tabletop Discussion Continuity of Operations

• All responding disciplines/agencies will
  experience challenges in delivering essential
  services during the upcoming pandemic!
• Even though there are no cases in California,
  responders must prepare for the eventual
  outbreaks in and impacts on our communities!
• What continuity of operations challenges will
  your organization/discipline face as the pandemic
  evolves?

61
Tabletop Discussion Access to Supplies

• What are your top 3 critical supplies and/or
  equipment your organization will need to respond?
• Does your organization have an adequate supply of
  these critical supplies to respond for at least
  96 hours, 1 week, 1 month?
• What processes does your organization have to
  procure/restock critical supplies?
• What critical services does your organization
  depend on to maintain essential services and
  remain open and functional?
• Have daily services been identified that can be
  postponed or curtailed to provide critical
  services?
• What back up plans does your organization have if
  critical services are disrupted?

62
Tabletop Discussion Workforce Issues

• Human resources will be critical to maintaining
  essential operations and functions for all
  organizations during a pandemic!
• What are your organizations strategies to
• Preserve the current workforce
• Augment the workforce
• Change service delivery to accommodate a
  declining workforce
• How can organizations and disciplines share
  limited personnel resources and/or consolidate
  services/activities/functions?

63
Tabletop Discussion Workforce Issues

• Human Resources
• Have you planned for the care of your personnel
  resources including
• Medical needs
• Psychosocial needs
• Stress management
• Food and water
• Identify other needs staff may have
• Has your organization planned to also provide or
  care for family members so personnel will come to
  work?

64
Tabletop Discussion Critical Issues for
Continuity of Operations

• During a pandemic, the capacity of healthcare
  providers and other responding agencies will be
  overwhelmed by demand for services!
• What are the top 3 critical issues and challenges
  for organizations in expanding services and
  capacities?
• 1.
• 2.
• 3.
• How can organizations support and assist each
  other in expanding capacity?

65
Tabletop Discussion Healthcare Surge

• Alternate care/ non-traditional care sites will
  need to be established to accommodate the surge
• What are the decision-making processes for
  expanding heatlhcare facility capacity and or
  activating/opening government authorized
  alternate care sites?
• Within your organization adapting current care
  areas?
• Community-based sites?
• How will patients be triaged to appropriate care
  sites?
• Who is in charge of destination decisions?
• How will patients be appropriately transported to
  alternate care sites?
• What communication technologies will ensure
  communications between traditional care sites and
  government authorized alternate care sites?

66
Tabletop Discussion Healthcare Surge

• Non-healthcare provider organizations, agencies
  and disciplines will be involved in managing the
  medical surge issues and challenges!
• What are the top 5 non-healthcare issues and
  challenges for establishing alternate care sites
  and managing medical surge?
• What is your organizations role in managing the
  healthcare surge issues?
• Emergency Management and Coordination
• Security and access of facility, equipment,
  personnel, medications
• Patient movement and transportation
• Dispatch
• Traffic and crowd control

67
Tabletop Discussion Mass Fatalities

• During the pandemic in our scenario, the Case
  Fatality Ratio is predicted to be a Category 4 or
  5
• Category 4 900,000 to lt 1.8 million deaths in
  the US (1.0 - lt 2 fatality rate)
• Category 5 1.8 million deaths in the US (2 or
  greater fatality rate)
• What is the role and capability of the local
  medical examiner/coroner during a pandemic with
  mass fatalities?
• Are they the lead in managing mass fatalities in
  the county?
• Who is?
• What are the roles and capacities of
  organizations in managing storage and disposal of
  bodies during a pandemic?
• Hospitals, Clinics, Long Term Care
• Local Public Health
• Local EMS Agency and EMS Providers

68
The Tabletop Concludes

• Identify 3 strengths, weaknesses, and areas
  for improvement in each target capability
• Communications
• Intelligence / Information Sharing
• Medical Surge (Patient Movement through the
  Continuum of Care)

69
The Scenario Evolves

• In April, 2009, the CDC reports focal outbreaks
  of respiratory illness and deaths in several
  states including
• Florida
• New York
• Ohio
• Texas
• The media are exaggerating numbers and severity
  of cases and public anxiety has risen to panic
• In California, healthcare providers are inundated
  with phone calls and people presenting with
  demands for control measures and medications
• Absenteeism has risen in schools, businesses, and
  essential organizations

70
The Scenario Evolves

• May 28, 2009
• The CDPH laboratory confirms the first case of
  H5N2 novel virus infection in California!
• The State Health Officer is expected to issue
  orders for
• Community mitigation strategies and measures to
  be implemented
• Student dismissals
• Cancellation of large public gatherings
• Emergency Operations Centers and organization
  command centers are fully activated
• This is the foundation for the June 18, 2009
  functional exercise!

71
Next Steps Planning for June 18, 2009 Functional
Exercise

• Planning for 2009 Statewide Health and Medical
  Functional Exercise
• Participants (Identify any missing partners)
• Level of Play-Objectives to be Tested
• Length of Play
• Planning Meetings

72
Develop an Action Plan
73
Lessons Learned

• Evaluate the Tabletop Exercise
• What were 3 key learnings from the tabletop?
• The ah-ha or oh-no moments for you?
• Was the tabletop helpful in identifying
• Key issues and challenges?
• Partner collaboration and networking needs?
• Future planning and preparation action steps?
• What could have been improved?
• Other overall comments and suggestions for the
  tabletop?

74

California Emergency Medical
Services Authority ? California Primary Care
Association ?
California Association of Health
Facilities ? California Hospital Association
2009 Statewide Medical and Health Exercise
Pandemic Influenza
Phase 3
Facilitated Tabletop Exercise Thank you for
your participation!