1

[Hospital Name] Bioevent Tabletop Exercise

Moderated by:and

Facilitated by:

[Hospital Logo]

[Local Health Department Logo]

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 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

Exercise Objectives

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 (debriefing) is the final component of the exercise followed by an exercise evaluation.

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

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

Hospital[Your institution]

• Certified beds –

• Staffed beds –

• Staff – FTEs

• ED visits –

• Airborne Infection Isolation Rooms –

[Graphic of your facility]

7

Module OneRecognition

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

[Day One] at 7:30 pm

• The emergency department has been busier than usual.

• Last week [Local DOH] announced an early start to the flu season and urged high-risk individuals to get flu shots.

• The ED has seen several cases of flu-like illness over the past two weeks.

10

[Day One] at 7:30 pm

• A 28 year old female reservist presents to the ED with complaints of fever, cough, mild shortness of breath and chest pain for the past 12 hours.

• She works as an ICU nurse on the day shift at [your hospital] and is pursuing her MPH at night at [NYU].

• She shares an apartment with three other students.

• Her exam is unremarkable with normal chest and cardiac exam and she has no prior medical conditions.

11

[Day One] at 7:30 pm

• Her chest X-ray shows no pulmonary infiltrates.

• A blood culture is drawn to rule out other conditions.

• The physician recommends bed rest and fluids and tells the young woman to seek medical care if her symptoms worsen.

12

[Day Two] at 6:30 am

• The young reservist seen yesterday evening returns to the ED with a higher temperature and shortness of breath.

• Her vitals are:Today YesterdayTemp 103 oF Temp 101 oFBP 85/50 BP 105/65HR 125 HR 102RR 30 RR 24O2 sat. 90%

• She has paroxysmal tachycardia and a heart murmur. A repeat Chest X-Ray is performed.

13

[Day Two] at 6:30 am

• The patient reports no history of heart murmur, thyroid problems, and is not using medications, drugs or alcohol.

• She’s a serious student and most of her time is either spent working or studying.

• She is an ardent baseball fan and occasionally attends a [Local baseball team] game when she has time or can get a ticket.

14

[Day Two] at 8:00 am

• The ED attending asks the unit secretary to pull the patient’s labs from last night.

• A repeat chest X-ray shows a new pleural effusion. A chest CT is ordered.

• He pages the ID attending for a consult and he gives orders for IV antibiotics and admits the patient.

15

[Day Two] at 10:00 am

• The young woman suddenly develops respiratory distress and is emergently intubated and transferred to the ICU where she rapidly becomes septic.

• Although she is given fluids and pressors, at 11:00 am she arrests and cannot be resuscitated.

• A post mortem is scheduled.

16

[Day Two] at 11:00 am

• The triage nurse notices a larger volume than normal for a [Day of Week] morning in the ED with many complaining of flu-like symptoms, especially upper respiratory ailments.

• Since yesterday evening [20] patients, all from different parts of the city, have presented with similar symptoms.

• The triage nurse, ED resident and ED attending discuss the current situation and attribute the unusually high numbers to the early flu season.

17

[Day Two] at 1:00 pm

• Isolation rooms are already full and many more patients with similar symptoms continue to present to the ED.

• There are now [thirty] people with fever and respiratory complaints, including cough and difficulty breathing. [Ten] of these patients are being processed for admission.

• There are an additional [two] patients with chest pain and [two] trauma patients awaiting admission.

• Patients on gurneys are lining the hallway.

• [Three] ED nurses scheduled for evening shift call in sick.

• Speculation is rife among the hospital staff particularly with the death of a previously healthy staff member.

18

Situation Report #1 [Specify dates for Day One and Two]

• Total suspect:• [25] Patients admitted• [30] In ED

• Fatalities: [1]• Total available beds by department:

• [5] Adult Medical/Surgery • [10] Pediatric Medical/Surgery• [1] ICU• [12] Other

19

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, infection control, supply, and environmental needs at this point?

First Breakout GroupReport Back

21

Module TwoResponse

22

[Day Two] at 4:00 pm

• After discussing with the patient’s attending [Your hospital] ICP notifies the [Local DOH] regarding:

• The blood cultures drawn on [Day One] from the young woman (the index case) who died have grown large gram positive bacilli.

• An increased number of patients with similar complaints are continuing to present to the ED.

• [Local DOH] states there are similar reports being received from other local hospitals.

23

[Day Two] at 10:00 pm

• [Local DOH] initiates epidemiological investigations in conjunction with the FBI and [local law enforcement] by sending a team on-site to [Your hospital] and four other hospitals where similar cases have been reported.

• Preliminary diagnosis of “Bacillus anthracis” is received from the Public Health Laboratory based on a positive direct fluorescent antibody (DFA) and PCR result.

24

[Day Two] at 10:30 pm

Local Health Department

[Year] ALERT #38: Presumptive case of Inhalational Anthrax in [New York City].

Please Distribute to All Medical, Pediatric, Family Practice, Laboratory, Critical Care, and Pharmacy Staff in Your Hospital

Dear Colleagues:

 The [your city] Public Health Laboratory has presumptively diagnosed a case of inhalational anthrax in a previously healthy 28 year-old female based on PCR and DFA testing. Further confirmatory tests will be performed by the Centers for Disease Control (CDC). Due to concern of bioterrorism, the [Local DOH], CDC and law enforcement authorities are actively conducting epidemiologic and environmental investigations; the exact location and source of the inhalational anthrax exposure is not yet known. [Local DOH] requests immediate reporting of any suspected case of anthrax…

25

Summary of Public Health and Other Governmental Agency Responses

• The City’s Emergency Operations Center is activated.

• Press briefing with the 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.

26

[Day Two] at 11:00 pm

• Patients are being referred to the ED by ambulatory care centers and community based outpatient clinics.

• Patient flow through the ED is hampered by lack of space and patients are also being evaluated in the waiting area and the ED conference room.

• Wait times in the ED for non-emergency patients are now abnormally high.

• Family members of several patients not yet admitted are beginning to panic and are starting to vent their mounting fears and frustration at the staff.

• This leads to increased anxiety amongst the staff and they request additional security in the ED.

27

[Day Three] at 7:00 am

• The Director of Nursing reports that [40%] of nursing personnel have called out sick for the morning 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 and cough

28

[Day Three] at 9:00 am

• All major local and national news networks are broadcasting round-the-clock information.

• Subject matter experts are speculating on the type of anthrax and are wondering if this is connected to the 2001 incidents at post offices, Capitol Hill, TV stations, etc.

29

Situation Report #2[Day 1-3, Enter Days of week]

• Total suspect: • [65] patients admitted• [86] in ED

• Total worried well in ED: [~65] • Fatalities: [2] • Total available beds by Department

• [1] Adult Medical/Surgery• [1] Pediatric Med/Surgery• [0] ICU• [2] Other

30

[Day Three] at 11:30 am

• Several baseball players from both playoff teams as well as coaches and umpires have been admitted to hospitals with anthrax symptoms.

• A preliminary investigation by [Local DOH] in conjunction with law enforcement shows all confirmed cases of anthrax to date were people who attended the local [Your City] playoff game on [Day One minus four] or who live or work downwind of the stadium.

• A decision is made to prophylax all persons who were at the ballpark that night as well as those living/working in zip codes within a given perimeter.

31

[Day Three] at 12:00 Noon

• A second alert is put out by [local DOH] updating the information on the outbreak:

• Bacillus anthracis had been confirmed by the Public Health Laboratory and the CDC.

• [Local DOH] has recommended the use of IV quinolone plus one other antibiotic for initial treatment.

• Preliminary epi data implicates the [Local baseball team’s playoff game] as the likely site of the anthrax release.

• Persons potentially exposed at the [playoff game] and in the general area require prophylaxis with oral ciprofloxacin or doxycycline. The City is setting up antibiotic clinics targeting those at risk.

32

DOH Health Alert (Continued)

• As inhalational anthrax is not transmissible person-to-person, standard precautions are adequate. Antibiotic prophylaxis of healthcare workers is not indicated.

• Hospitals should continue to admit and treat patients who are symptomatic.

• All suspect cases should continue to be reported to the DOH, regardless of exposure history.

33

Module TwoBreakout Group Discussion

• How will you handle the increasing number of ill? Worried well?

• Where and how will you set up triage?

• What supply and materials management issues will be critical to address?

• What are your communication needs?

• How will you handle communication with the media? Who will you coordinate with?

Second Breakout GroupReport Back

35

Break

36

Module ThreeSurge Capacity

37

[Day Three] at 12:00 pm

• The emergency department is swamped with patients with non-specific complaints and without fever seeking medical attention.

• Wait time for non-emergent patients is exceeding [twelve] hours.

• The number of patients waiting to be seen exceeds hospital capacity.

• EMS is overwhelmed.

38

[Day Three] at 4:00 pm

• The Local Office of Emergency Management (OEM)] and [Local DOH] have set up points of distribution (PODS) to dispense antibiotics starting at 5:00 pm today.

• Each individual will initially receive a ten-day supply.

• Additional distribution will occur once additional antibiotic supplies arrive from the Strategic National Stockpile (SNS).

39

[Day Three] at 4:00 pm

• Reports of potential shortages of antibiotics have resulted in hordes of people seeking out their primary care physicians, clinics and emergency departments throughout [Your City].

• There are long lines outside many facilities.

• News crews are camped outside all major healthcare facilities.

40

[Day Three] at 4:00 pm

• [Your hospital’s] emergency department and outpatient treatment areas continue to be inundated 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.

41

Situation Report #3[Day 1-3, Enter Days of Week]

• Total suspect: • [At capacity] patients admitted• [250] in ED• [60] in secondary triage area

• Total worried well in ED: [~50] • Fatalities: [3] • Total available beds by Department

• [0] Adult Medical/Surgery• [0] Pediatric Med/Surgery• [0] ICU• [0] Other

42

Government Agency Responses

• The Governor has requested resources from the Federal Government and the National Disaster Medical System has been activated.

• Points of Distribution Clinics are providing antibiotics to those determined to be exposed at [Local Baseball Stadium]

• [DOH] is maintaining a provider and public hotline, and continuing its active case 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, provide safety recommendations and minimize impact of the worried well on hospitals.

43

Module Three Group Discussion

• How well does your Emergency Management Plan address surge capacity?

• How will you direct persons coming to the ED for antibiotic prophylaxis to the nearest antibiotic clinic?

• 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)?

44

BT Attack at [Local Baseball] stadiumSome additional history …

45

Hot Wash

• What have you learned during this tabletop exercise?

• What are the hospital’s emergency management preparedness 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

Thank you!