Hospital Name

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Hospital Name

Bioevent Tabletop Exercise
Moderated 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
• Identify triggers for activating the incident
  command system
• 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

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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 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 (AIIRs)

Graphic of your facility
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Module OneRecognition

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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.

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Day One at 330 pm

• The emergency department is busy as usual
• Exam rooms are filled, staff are busy, tensions
  are high
• Wait times for non-emergent patients is exceeding
  six hours. Getting patients admitted to a
  room seems to be taking longer than usual
• Ambulance traffic is steady the midday backup
  of vehicles is taking its toll

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Day One at 330 pm

• A 36 year-old man arrives at the ED by ambulance
  from local outpatient clinic to be admitted for
  pneumonia.
• Hes complaining of fever, chills, nausea, and
  general malaise.
• On exam his vital signs are temp 101.2oF, HR 108,
  BP 96/50, O2 saturation 93 on room air, and RR
  24 with crackles at the right base.

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Day One at 630 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 400 am.

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Day Two at 630 am

• During morning rounds the medical team finds that
  throughout the previous night, the patient had
  continuous fever of 102 oF and several episodes
  of vomiting.
• On exam he has worsening respiratory function,
  increasing lethargy, and there is a question of
  nuchal rigidity.

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Day Two at 630 am

• The patients sister states that her brother has
  been previously well with no history of medical
  problems.
• Hes traveled both domestically and
  internationally on political advocacy business.
• He arrived in Name of your city to visit his
  sister four days ago from Denver.

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Day Two at 730 am

• The case is presented during rounds and the
  attending requests that a lumbar puncture be done
  immediately
• When the resident goes into the patients room to
  prep him, he finds the patient extremely short of
  breath with an O2 sat of 82 on 5 liters of
  oxygen
• Hes emergently intubated and moved to the ICU
• He later becomes hypotensive, codes and dies
• The patients family agrees to a post-mortem

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Day Two at 830 am

• Admissions from the ED are lining the hallway
  wait time for inpatient beds is averaging 12
  hours.
• Fifteen patients are awaiting admission
• 10 with pneumonia, two of whom are six year-old
  twins, whose parents are extremely anxious
• 3 with chest pain and
• 2 trauma patients requiring surgical beds.
• Four ED nurses scheduled for the morning shift
  call in sick.

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Day Two at 200 pm

• The ICU attending is watching the local news on
  Channel 4 in a patients room while waiting for
  him to return from X-ray.
• She hears local reporters name reporting on
  the death of a city official from an acute
  respiratory illness.
• The aide to this official is in the ICU at other
  local hospital with a respiratory illness and is
  listed in serious condition.

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Day Two at 215 pm

• A few minutes later the ICU attending is paged by
  the ED resident.
• Six of the ten pneumonia patients in the ED,
  including 6 y.o. twins, require ICU admission.
• All are hypotensive with fever and shortness of
  breath intubation anticipated or underway for
  all six.
• Nurses are starting to talk amongst themselves
  about the cases and speculation is rife.

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Situation Report 1 Specify dates for Day One
and Two

• Total suspect
• 10 patients admitted
• 4 to ICU
• 2 to Pediatric ICU
• Total worried well in ED 50
• Fatalities 1
• Total available beds by Department
• 5 Adult Medical/Surgery
• 3 Pediatric Med/Surgery
• 1 ICU
• 12 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.
• How will your hospital meet the current demand
  for beds and staffing?
• What are your 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 Three at 830 am

• The hospital ICP notified the Local DOH
  yesterday afternoon regarding
• The unusual number of severe respiratory cases
  presenting to the ED.
• A lab report indicating gram negative rods w/
  bipolar staining from the blood cultures of the
  index case admitted on Day One
• Local DOH initiated an onsite epidemiological
  investigation, in coordination with FBI and
  Local Police Department.
• Specimens were sent to the Bio-Threat Laboratory
  at the Local Public Health Lab a presumptive
  diagnosis was made for Yersinia pestis by PCR and
  DFA testing.
• The Local DOH contacted the Colorado Dept. of
  Health who were not able to identify any risk
  exposures for plague near the index cases
  residence.

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Day Three900 am Health Alert
Year ALERT 38 Presumptive case of Pneumonic
Plague 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   The your city Public Health
Laboratory has presumptively diagnosed a case of
pneumonic plague in a previously healthy 36
year-old male resident of Colorado. To date no
other cases of plague have been described in
humans or Yersinia pestis in rats in Colorado. A
blood culture tested positive for Yersinia pestis
last night by both polymerase chain reaction and
direct fluorescent antibody testing. Further
confirmatory tests will be performed by the
Centers for Disease Control (CDC). Local DOH,
CDC and law enforcement authorities are actively
conducting epidemiologic and environmental
investigations the exact location and source of
plague exposure is not yet known. Local DOH
requests immediate reporting of any suspected
case of plague
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Summary of Public Health and Other Governmental
Agency Responses

• Citywide Emergency Operations Center activated
• Press briefing with 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

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Day Three at 930 am

• The five critical patients admitted to the ICU
  remain on vents, all have acute respiratory
  distress syndrome and sepsis.
• One of the pediatric ICU patients has expired
• All five patients are isolated and given IV
  antibiotics, fluids, and pressors.
• Several other pneumonia patients in ED awaiting
  admission are deteriorating and intubation is
  being contemplated for four.
• Many hospital employees are requesting antibiotic
  prophylaxis.

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Situation Report 2 Day 1-3

• Total suspect
• 25 patients admitted
• 10 in ICU
• 15 in ED
• Total worried well in ED 65
• Fatalities 2
• Total available beds by Department
• 5 Adult Medical/Surgery
• 2 Pediatric Med/Surgery
• 1 ICU
• 12 Other

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Day Three at 430 pm

• The Director of Nursing reports that 20 of
  nursing personnel have called out sick for the
  night shift as have numerous house staff and
  physicians.
• Other your city hospitals are reporting similar
  staff shortages.
• House officer reports to work with fever and
  cough.

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Module TwoBreakout Group Discussion

• How will you handle the increasing number of ill
  and worried well?
• Where and how will you set up triage for
  screening and isolation?
• Where will you admit all the patients needing
  Droplet Precautions?
• 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?

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Second Breakout Group Report Back
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Break
Fifteen Minutes Please
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Module Three
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Day Four at 1030 am

• 150 patients with non-specific complaints and
  without fever are seeking medical attention.
  Wait time in the ED for non-emergent patients is
  still exceeding 12 hours.
• The hospital is operating at capacity.
• EMS is also extremely busy.

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Day Four at 200 pm

• Major local and national news channels are
  running continuous coverage of the events.
• The networks are speculating about the source of
  the outbreak and the risk for additional
  terrorism events in the city. Reporters are
  lined up outside the hospital asking staff and
  visitors for on-camera interviews.

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Day Five at 1200 pm

• Your hospitals emergency department and
  outpatient treatment areas continue to be swamped
  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.

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Day Five at 1200 pm

• Attention is focused on planning for the
  management of fatalities, given limited capacity
  in the hospital morgue

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Situation Report 3 Day 1-5

• Total suspect
• patients admitted
• in ED
• in ICU
• Total worried well in ED
• Fatalities
• Total available beds by Department
• Adult Medical/Surgery
• Pediatric Med/Surgery
• ICU
• Other

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Government Agency Responses

• The governor has requested resources from the
  Federal Government and the National Disaster
  Medical System has been activated
• Local DOH and Office of Emergency Management
  have set up points of distribution for dispensing
  antibiotics
• Based on the latest epidemiologic findings,
  Local DOH, Local Police Dept. and FBI are
  conducting an environmental and forensic
  investigation at the presumed site of the attack
• Local DOH is maintaining a provider and public
  hotline, and continuing its active surveillance,
  regular health alerts and daily hospital
  conference calls
• Local DOH and OEM 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.

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Module ThreeGroup 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)?

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Fourth of July at South Street Seaport Some
additional history
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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 in 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!