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 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 (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 (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 730 pm

• A 20 year old woman is brought to the ED by her
  father with chief complaint of 48 hours of severe
  headache, lower back pain, nausea, anorexia and
  high temps.
• Her vitals are BP 80/50, HR 110, RR 18 and Temp
  104o and she is ill enough to require immediate
  admission.

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Day One at 730 pm

• The woman is a student at Columbia University
  and shares an apartment on the Upper West Side
  with three other students.
• Her parents live in Another part of the same
  City e.g., Brooklyn and she came home for the
  weekend to celebrate her younger brothers 9th
  birthday.
• Her mother is with her younger brother waiting to
  be seen by a pediatrician in the ED as he has
  similar complaints, including several episodes of
  vomiting.

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Day Two at 830 am

• On morning rounds the medical team notes that the
  patient admitted yesterday had continued fevers
  ( 104 oF) with several episodes of vomiting.
• She is confused and has developed worsening
  hypotension. She is transferred to the Medical
  Intensive Care Unit (MICU).
• Her younger brother has developed a sepsis-like
  syndrome and is admitted to the pediatric ICU.

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Day Two at 830 pm

• In the MICU, the intern-on-call notes vesicular
  lesions in her mouth and on the upper
  extremities. He immediately calls the infectious
  disease attending for additional consultation.

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Day Two at 900 PM

• That same evening the ED Charge Nurse tells the
  ED attending that 25 more patients have been
  triaged over the past four hours with high
  fever, myalgia, headache or low back pain, many
  of whom are in the waiting room awaiting further
  evaluation.
• In addition, the patients brother in the
  pediatric ICU has developed a vesicular rash on
  his face and continues to have temps of 103oF.

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Situation Report 1 Specify dates for Day One
and Two

• Total suspect
• 2 patients admitted
• 25 in ED
• Fatalities 0
• 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 800 a.m.
The hospital ICP notified the Local DOH
yesterday evening regarding The
admission of 2 patients with high temperatures
and vesicular rashes The unusual number of
cases with high fever presenting to the ED
Local DOH initiated an onsite epidemiological
investigation, in coordination with the FBI and
Local Police Department Specimens were
sent to the CDC and Public Health Laboratory
yesterday evening.
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Day Three at 1230 pm

• Results of the orthopox PCR are positive from the
  NYC Public Health Laboratory and confirmation
  from CDC is pending.
• Local DOH issues a health alert and implements
  a citywide hospital conference call to provide
  clinical and epidemiologic information and
  updates.

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Day Three at 100 pm
Local Health Department year ALERT 38
Presumptive case of Smallpox in Your city
The DOH has presumptively diagnosed a case of
smallpox in a 20 year old female Your City
resident. Laboratory results on her 9 year old
younger brother are pending. Your City DOH
requests immediate reporting of similar cases to
Health Department Please distribute to All
Medical, Pediatric, Family Practice, Laboratory,
Critical Care, Pulmonary, Dermatology, Employee
Health, and Pharmacy Staff in Your
hospital Dear Colleagues, The City Public
Health Laboratory has presumptively diagnosed a
case of smallpox in a 20 year old women. She
presented to a City hospital on Sunday evening
with severe headache lower back pain, rash,
nausea, anorexia and high fever. She was
accompanied by her 9 year old brother who had
similar complaints. As the last naturally
occurring human case of smallpox worldwide
occurred in Somalia in 1977 and known stocks of
smallpox are limited to two labs (Atlanta and
Moscow), this case is presumed to be evidence of
a bioterrorist attack. DOH, CDC and law
enforcement authorities are actively conducting
epidemiologic and environmental investigations
the exact location and source of smallpox
exposure is not yet known. The DOH requests
immediate reporting of any suspected case of
smallpox..

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Summary of Public Health and Other Governmental
Agency Responses

• The Citys Emergency Operations Center is
  activated
• Press briefing with Mayor, Commissioner of Health
  and law enforcement agencies is held
• Local DOH initiates citywide active
  surveillance, contact tracing and epidemiologic
  investigation to determine source.
• Plans for mass vaccine clinics put into place
• Daily citywide hospital conference calls
  initiated to provide updates

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Day Three at 100 pm

• Both the index case and her brother have expired
  during the past 12 hours.
• 20 persons from last night were admitted to the
  hospital for probable smallpox.
• An additional 50 patients have presented to the
  ED in the past 12 hours with clinical symptoms
  suggestive of smallpox.
• It is snowing and the temperature outside is
  falling.

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Day Three at 200 pm

• Hospitals are requested to provide smallpox
  vaccination to all of their employees, patients
  and emergency medical services workers.
• Local DOH asks for the approximate number of
  vaccine doses that will be needed.
• Vaccine will be available to the hospital within
  six hours

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Situation Report 2 Specify dates for Day 1 - 3

• Total suspect
• 100 patients admitted or in the process
• Total worried well in ED 70
• 150 employees requesting smallpox vaccine
• Fatalities 2
• 30 requiring admission for non-event related
  diagnosis
• Total available beds by Department
• 5 Adult Medical/Surgery
• 3 Pediatric Med/Surgery
• 0 ICU
• 6 Other
• 0 Telemetry

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Day Three at 430 pm

• The Director of Nursing reports that 40 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.
• A House officer reports to work with fever.

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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 assure appropriate isolation
  procedures are followed?
• 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?

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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 Four at 1030 am

• Many patients with non-specific complaints and
  without fever are seeking medical attention.
  Wait time in the ED for non-emergent patients is
  still exceeding 24 hours.
• The number of patients waiting to be seen exceeds
  hospital 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 Four at 300 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 Four at 400 pm

• The Vice President of Clinical Services reports
  that nursing personnel and other healthcare
  workers are calling in sick making it difficult
  to provide sufficient staff for inpatient care.
• Other Your City hospitals are reporting similar
  staff shortages.
• Two house officers report to work with fever and
  cough.

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Day Four at 400 pm

• The Office of Emergency Management (OEM) and
  Local DOH have set mass vaccine clinics to
  vaccinate the public starting at 500 pm today.
• The ED staff is attempting to triage about 150
  worried well to these sites for vaccination.

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Day Five at 500 pm

• Over the five-day period, 30 patients have
  died of smallpox at your facility.
• Attention is focused on the management of
  fatalities as hospital morgues are full and
  funeral parlors are overwhelmed by requests to
  attend to deceased loved ones.
• Number of daily admissions at hospitals citywide
  is increasing.
• Staff is exhausted and requesting time off.

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Situation Report 3 Specify Dates for Days 1-5

• Total suspect
• 125 patients admitted or in the process
• Total worried well in ED 250
• Fatalities 30
• 20 requiring admission for non-event related
  diagnosis
• Total available beds by Department If there are
  any available beds enter them here
• 5 Adult Medical/Surgery
• 3 Pediatric Med/Surgery
• 1 ICU
• 12 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
• 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
  smallpox attack
• Local DOH is maintaining a provider and public
  hotline, and continuing its active surveillance
  and contact tracing, regular health alerts and
  daily hospital conference calls. Mass vaccine
  clinics are operating 24 hours per day.
• Local 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.

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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)?

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Day One minus 12 Bio-Release at Macys
Thanksgiving Parade
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Hot Wash

• What have you learned during this tabletop
  exercise?
• What are the hospitals Emergency Management Plan
  strengths?
• What are the Emergency Management Plans
  weaknesses / gaps?
• 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!