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BP 5- Attachment- #8

Rev. April 2013 HSEEP-IP01

Chaos and Confusion Regional Functional Exercise After-Action Report/Improvement Plan Exercise Date: June 6, 2017 Submitted June 28, 2017 Most Recent Revision: August 15, 2017

Clark County Combined Health District The After-Action Report/Improvement Plan (AAR/IP) aligns exercise objectives with preparedness doctrine to include the National Preparedness Goal and related frameworks and guidance. Specific to this report, the exercise objectives align with ASPR’s National Guidance for Healthcare Preparedness and the Hospital Preparedness Program Measures. Public Health Emergency Preparedness Capabilities are referenced as well. Exercise information required for preparedness reporting and trend analysis is included; additional sections have been added as a record upon which to build improvement.



Record of Review and Change Date Description By Whom

06/28/2017 AAR/IP created and submitted to ODH C. Conover

C. Conover

07/11/2017 Added Appendix I to break down strengths/ improvements according to the 6 critical areas according to The Joint Commission.

C. Conover/ B. Dorsey

07/13/2017 Added Table of Contents C. Conover 08/15/2017 Improvement Plan of this document was reviewed with

CCCHD Administrative Team. C.Conover



Table of Contents Page

Exercise/Incident/Event Overview 1 Executive Summary 3 Analysis of Health Care Preparedness Capabilities 5

• HPP #10 Medical Surge 8

• HPP #6 and PHEP #6 Information Sharing 9

• PHEP #8 Medical Counter Measures 12

• PHEP #9 Medical material Management and Distribution 13

• PHEP #15 Volunteer Management 14

Conclusion 15 Appendix A: Improvement Plan A-1 Appendix B: Exercise Participants A-6 Appendix C: Acronyms and Abbreviated Terms A-8 Appendix D: Participant Feedback Summary A-10 Appendix E: Exercise Events Summary A-15 Appendix F: OPHCS Message Report A-20 Appendix G: ICS Form 205 A-24 Appendix H: Additional Example Documentation A-27 Appendix I: Strengths/Opportunities by Performance Areas A-37

After-Action Report/ Chaos and Confusion Regional Functional Exercise Improvement Plan (AAR/IP) West Central Ohio

Exercise Overview 1 GDAHA – CCCHD- Clark County, OH

Homeland Security Exercise and Evaluation Program (HSEEP)

EXERCISE/INCIDENT/EVENT OVERVIEW

Exercise Name Chaos and Confusion Regional Functional Exercise

Exercise Dates June 6, 2017

Scope This is a functional exercise, planned for four hours during a one day period at multiple locations throughout West Central Ohio. Exercise play is limited to each county and the simulation cell.

Mission Area(s) Protection, Mitigation, and Response.

Public Health Preparedness Capabilities

• HPP Capability #10 - Medical Surge • HPP Capability #6 - Information Sharing • PHEP Capability #6 – Information Sharing • PHEP Capability #8 - Medical Counter Measures • PHEP Capability #9 - Medical Material Management and Distribution • PHEP Capability #15 – Volunteer Management

Objectives

HPP #10 Medical Surge: Demonstrate the ability to provide adequate medical evaluation and care during a mass casualty incident that exceeds the limits of normal day-to-day operations.

HPP #6 & PHEP #6 Information Sharing:

• Demonstrate the ability to share health related, response information, and situational awareness data among all partners.

• Demonstrate the ability to access and use both MARCS and OPHCS during a biological incident.

PHEP #8 Medical Counter Measures: Demonstrate the capability to plan and prepare for providing countermeasures in support of prophylaxis to the identified population in accordance with public health guidelines and/or recommendations.

PHEP #9 Medical Material Management and Distribution: Demonstrate the ability to request, maintain, and track SNS medical materials during a simulated biological incident. (EEGs will be used to address hospital request of SNS materials)

PHEP #15 Volunteer Management: Demonstrate that processes are in




place to request and activate volunteers to support the jurisdictions public health agency’s response during a simulated biological incident.

Threat or Hazard Biological Terrorist Incident

Scenario

The scenario for this exercise utilizes localized but severe impacts to the community resulting from a terrorist biological incident. Cascading events will exceed the capability for local agencies resources to respond to the incident. Coordination with state and federal partners will be needed to access assets to mitigate the effects of the terrorist biological incident.

Sponsor Greater Dayton Area Hospital Association with funding provided from the Ohio Department of Health through the Assistant Secretary for Preparedness and Response grant.

Participating Organizations The full list of participating agencies is listed in Appendix B.

Point of Contact

Christina Conover, Emergency Preparedness Coordinator (EPC), Clark County Combined Health District (CCCHD) 529 East Home Road, Springfield, OH 45503; 937-390-5600 ext. 279 [email protected]

mailto:[email protected]




Executive Summary

The West Central Ohio Functional Exercise titled “Chaos and Confusion” was conducted on June 6, 2017. It focused on assessing a coordinated response to a biological terrorist incident on the WCO region.

This After-Action Report (AAR) is used to document effectiveness and overall exercise performance. Exercises serve as “final accountability” of collective preparedness.

The AAR/IP serves as a compendium of lessons learned, outlines recommended improvement plans, and provides the basis for planning future exercises. This AAR will contribute to improving preparedness for hospitals, public health, emergency management agencies (EMA) and other hospital coalition partners throughout the West Central Ohio (WCO) Region.

Exercise Planning Team: CCCHD’s EPC was included on the planning team which was composed of representatives from hospitals, public health and public safety departments. The exercise planning team met approximately 6 times between December 2016 and June 2017.

Objectives: Six objectives were selected for testing in addition to the annual Strategic National Stockpile (SNS) drills for the hospitals.

Location: This Functional Exercise was played from various locations among the eight county region of West Central Ohio. In Clark County, there were 4 sites of play:

• Clark County Combined Health District office; hosting o CCCHD players o Mental Health Services of Champaign and Madison County (MHS) o Clark County Emergency Management Agency (EMA) o Vancrest of New Carlisle (Vancrest) o Hospice of Miami Valley (HOMV)

• Oakwood Village (Oakwood) • Rocking Horse Community Healthcare Center (RHCHC • Springfield Regional Medical Center (SRMC)

This report will document the analysis of exercise results, identify strengths to be maintained, identify areas for further improvement, and support development of corrective actions.

Major Strengths

The major strengths identified during this exercise are as follows: 1. (Region) Numerous hospitals were able to utilize triage areas outside of the main hospital

structure. 2. (Region and Clark) Regional Health Commissioners conference call ensured all health

departments were following a similar response. 3. (Region and Clark) The Ohio Department of Health maintains an antibiotic cache for

disasters. 4. (Clark) CCCHD has a Volunteer Management plan which demonstrates county and regional

collaboration by including references to county and regional planning tools.




Primary Areas for Improvement

Throughout the exercise, several opportunities for improvement in West Central Ohio’s ability to respond to the incident were identified. The primary areas for improvement are listed below.

1. (Region and Clark) More robust information sharing procedures were needed by multiple partners across the individual counties as well as the region.

2. (Region and Clark) A better understanding of the roles and responsibilities for response organizations concerning the SNS.

3. (Region and Clark ) There is a need to increase the number of volunteers across the region.

4. (Clark) There is a need for better understanding of Public Health’s role in medical surge needs within the community.

5. (Clark) Closed POD program needs to be expanded. Overall, this exercise was a success. Participants had the opportunity to work with multiple partners in working to address the mitigation of a terrorist biological incident. It identified gaps or shortfalls in areas such as understanding of roles and communication shortcomings. By providing suggested corrective actions to be taken it will improve these capabilities within the region.


Analysis of Core Capabilities 5 Greater Dayton Area Hospital Association


ANALYSIS OF HEALTHCARE PREPAREDNESS CAPABILITIES Aligning exercise objectives and healthcare preparedness capabilities provides a consistent taxonomy for evaluation that transcends individual exercises to support preparedness reporting and trend analysis. Table 1 includes the exercise objectives, aligned core capabilities, and performance ratings for each core capability as observed during the exercise from a regional perspective.

Objective Public Health Preparedness

Capability/HPP Capability

Performed without

Challenges (P)

Performed with Some

Challenges (S)

Performed with Major Challenges

(M)

Unable to be Performed

(U)

Demonstrate the ability to provide adequate medical evaluation and care during a mass casualty incident that exceeds the limits of normal day-to-day operations.

HPP #10 Medical Surge

Hospitals (SRMC)

HCPs (RHC)

Inpatient Mental Health

(MHS)

Long Term Care (LTC):

Vancrest Oakwood

Hospice: HOMV

Demonstrate the ability to share health related, response information, and situational awareness data among all partners.

HPP Capability #6 - Information Sharing PHEP Capability #6 – Information Sharing

Hospitals

LHDs (CCCHD) LTCs

Hospices

HCP

MHS

EMA






Performed without

Challenges (P)

Performed with Some

Challenges (S)


(M)


(U)

Demonstrate the ability to access and use both MARCS and OPHCS during a biological incident.

HPP Capability #6 - Information Sharing PHEP Capability #6 – Information Sharing

Hospitals

LHDs

Demonstrate the capability to plan and prepare for providing countermeasures in support of prophylaxis to the identified population in accordance with public health guidelines and/or recommendations.

PHEP Capability #8 - Medical Counter Measures

LHDs

Demonstrate the ability to request, maintain, and track SNS medical materials during a simulated biological incident.

PHEP Capability #9 - Medical Material Management and Distribution

Hospitals

LHDs

EMA

Some involvement:

LTCs

HCP

Hospice

MHS






Performed without

Challenges (P)

Performed with Some

Challenges (S)


(M)


(U)

Demonstrate that processes are in place to request and activate volunteers to support the jurisdictions public health agency’s response during a simulated biological incident.

PHEP #15 Volunteer Management

Hospitals

LHD

Ratings Definitions: • Performed without Challenges (P): The targets and critical tasks associated with the healthcare preparedness capability were completed in a manner that

achieved the objective(s) and did not negatively impact the performance of other activities. Performance of this activity did not contribute to additional health and/or safety risks for the public or for emergency workers, and it was conducted in accordance with applicable plans, policies, procedures, regulations, and laws.

• Performed with Some Challenges (S): The targets and critical tasks associated with the healthcare preparedness capability were completed in a manner that achieved the objective(s) and did not negatively impact the performance of other activities. Performance of this activity did not contribute to additional health and/or safety risks for the public or for emergency workers, and it was conducted in accordance with applicable plans, policies, procedures, regulations, and laws. However, opportunities to enhance effectiveness and/or efficiency were identified.

• Performed with Major Challenges (M): The targets and critical tasks associated with the healthcare preparedness capability were completed in a manner that achieved the objective(s), but some or all of the following were observed: demonstrated performance had a negative impact on the performance of other activities; contributed to additional health and/or safety risks for the public or for emergency workers; and/or was not conducted in accordance with applicable plans, policies, procedures, regulations, and laws.

• Unable to be Performed (U): The targets and critical tasks associated with the healthcare preparedness capability were not performed in a manner that achieved the objective(s).

Table 1. Summary of Healthcare Preparedness Capability Performance




The following sections provide an overview of the performance related to each exercise objective and associated core capability, highlighting strengths and areas for improvement.

Objective 1: Demonstrate the ability to provide adequate medical evaluation and care during a mass casualty incident that exceeds the limits of normal day-to-day operations.

The strengths and areas for improvement for each HPP capability aligned to this objective are described in this section.

HPP #10 Medical Surge

• Activity 1: The Healthcare Coalition assists with the coordination of the healthcare organization response during incidents that require medical surge.

• Activity 2: Assist healthcare organizations with surge capacity and capability. • Activity 3: Assess the nature and scope of the incident. • Activity 4: Contingency plans discussed and/or activated.

Strengths

The partial capability level can be attributed to the following strengths:

Strength 1: (Region) Multiple hospitals established triage areas outside of the hospital to assist with influx of patients and to limit what was hitting their Emergency Departments.

Strength 2: (Clark) Health care organizations in Clark County demonstrated robust agency level responses from Healthcare Organizations playing in Clark County (i.e. shelter in place, lockdown, supply line alternatives, use of corporate assets.)

Strength 3: (Clark) Hospice and Mental Health Services demonstrated plans to support other partner agencies by providing additional services as part of the community’s response due to multiple deaths.

Areas for Improvement

The following areas require improvement to achieve the full capability level:

Area for Improvement 1: (Region) Delay with some hospitals dealing with in-patient units assessing potential discharges and transfer out of hospital.

Reference: Local Hospital Response Plans and SOPs.

Analysis: Multiple hospitals mentioned that a number of new staff we’re playing in a regional exercise for the first time. Thus experience on decision-making in this type of incident was limited as some sites. Options include more overlap between veteran staff and newcomers or additional training for newer staff before actual exercise.

Area for Improvement 2: (Region) Kindred hospital was overlooked as a resource for freeing up inpatients from other hospitals.

Reference: Local Hospital Response Plans and SOPs.




Analysis: Kindred hospital was contacted for number of available beds but no one ever took advantage of the actual resource. Unless organizations make it a standard procedure to contact both facilities this will continue to be an unused resource. Kindred as well as Life-Care are facilities that would be available to accept in-patients from other hospitals to free up beds to deal with the medical surge incident. Both of these facilities should be added to internal SOPs to ensure the facility is contacted in a time of need. Additionally, it might be beneficial for GDAHA to also have this available within their SOPs.

Area for Improvement 3: (Region and Clark) There is a need across the region for better information to partners about medical surge issues within the hospitals.

Reference: Local Hospital Response Plans and SOPs; Public Health Preparedness Capabilities, CCCHD ERP.

Analysis: Reporting of reportable diseases from hospitals to local health departments routinely happens on a day-to-day basis. Even though all LHDs should have access to OHTRAC now it does not mean it is monitored on a daily basis. During a large comparable incident it would be beneficial for all if the information was shared in a timely manner. It could be as simple as informing GDAHA and having them forward the information to either the LHD or regional PH coordinator. In Clark County, more users of OHTRAC must be identified and trained.

Area for Improvement 4: (Clark) Need increased familiarity with the regional biological and epidemiology plans.

Reference: Regional Biological and Epidemiological Plan.

Analysis: Increased familiarity is needed to ensure that Clark County is able to cooperate well with the West Central Ohio Region by utilizing the assumptions and predetermined plans.

Objective 2:

2a. Demonstrate the ability to share health related, response information, and situational awareness data among all partners.

2b. Demonstrate the ability to access and use both MARCS and OPHCS during a biological incident.

The strengths and areas for improvement for each HPP/PHEP capabilities aligned to these objectives are described in this section.

HPP #6 and PHEP #6 Information Sharing

• Activity 1: Provide healthcare situational awareness that contributes to the incident common operating picture (HPP/PHEP).

• Activity 2: Develop, refine, and sustain redundant, interoperable communication systems (HPP).

• Activity 3: Identify stakeholders to be incorporated into information flow (PHEP).




• Activity 4: Exchange information to determine a common operating picture (PHEP)

Strengths


Strength 1: (Region) Regional health commissioner’s conference call was completed within the first hour ensuring all local health departments were operating from the same information.

Strength 2: (Region and Clark) Redundant interoperability using MARCS radios was established early between hospitals and local health departments during the exercise.

Strength 3: (Region and Clark) Health Alert Network (HAN)/ OPHCS was used to get key incident response information to partners.

Strength 4: (Region) Numerous locations identified that IC within HICS/DOC provided situational update on hourly basis.

Strength 5: (Clark) Good success and evidence of use of ICS forms, particularly for communicating general messages and closing circle for resolution. Forms utilized included ICS 214, 213 RR, 213, 205, 206, etc. See Attachments.

Strength 6: (Clark) Partner Healthcare Organizations communicated frequently with Communicable disease unit regarding individual case information. This is evidenced by documented 213 and 214 forms created during the exercise. This strength is separate from the gap noted in areas for improvement, which speaks to situational awareness.

Strength 7: (Clark) EMA was able to assist with information sharing to partners particularly in acting as a liaison with Law Enforcement.

Strength 8: (Clark) In review of exercise documentation, there was evidence of research and outreach regarding safety of responders both internal to CCCHD and external such as first responders. This is in line with the Public Health Preparedness capabilities. In example, the type of PPE and disinfection processes for tularemia were available due to research to establish a known profile of the biological threat.



Area for Improvement 1: (Region and Clark) It was observed at multiple locations that information was not being readily shared with all partners dealing with the response.

Reference: Local Communications Plans and SOPs.

Analysis: Hospitals, LHDs, and other participating organizations stated that they could have shared more information and wanted to receive more information. Contact lists should be updated and new organizations added to ensure partners are updated on key situational information. There will be times during an actual incident where communication will be limited. Redundancies put in place now will ensure the possibility of open communications lines during




an actual disaster. Additionally, in Clark County, more robust Information Sharing procedures must be put into place. The barrier was not communication systems, rather a general need to increase the priority of information sharing and engaging partners proactively.

Area for Improvement 2: (Region and Clark) There was confusion on messaging concerning SNS assets and the cache maintained by ODH.


Analysis: A memo generated by a participating organization during the exercise stated that the SNS would be here in 3 hours when it was actually referring to the ODH cache. The SNS assets would arrive roughly between 18 to 24 hours. The state cache could arrive in roughly 3 hours. Additional information needs to be gathered concerning the State cache.

Area for Improvement 3: (Region) There were multiple sites complaining of communication issues where phone lines did not roll over and radio use was causing computer issues.


Analysis: A number of sites have recently added new phone lines that are intermixed with older systems. Due to this some phones which were set-up to rollover would never ring on the receiving end. In addition some sites had radios that were overriding and shutting down computers. Organizations should review their communication assets to ensure there is happy medium of the new and old merging together instead of canceling out each other.

Area for Improvement 4: (Clark) Information did not always flow well within the public health DOC.

Reference: Local Public Health ERPs and SOPs.

Analysis: Struggled to find battle rhythm during exercise to allow for round the room updates. Additionally, there is some apprehension about roles. The EPC received many requests from players for more specific direction for role in the DOC. Job Action sheets need to be developed with more detail.

Area for Improvement 5: (Clark) Animal and Agriculture resources need to be available for consult; partners expect this kind of information from public health.

Reference: Local Public Health ERPs and SOPs.

Analysis: Animal welfare is an important aspect of a community’s response and in the absence of another lead agency, public health will be expected to respond in the matters of animal health in light of threat.

Objective 3: Demonstrate the capability to plan and prepare for providing countermeasures in support of prophylaxis to the identified population in accordance with public health guidelines and/or recommendations.

The strengths and areas for improvement for each PHEP capability aligned to this objective are described in this section.




PHEP Capability #8 - Medical Counter Measures (MCM)

• Task 1: Engage subject matter experts (e.g., epidemiology, laboratory) and local partners, to determine what medical countermeasures are best suited for the incident.

• Task 2: Engage subject matter experts (e.g., epidemiology, laboratory) and local partners, to determine what medical countermeasures are available for the incident.

• Task 3: During incident, engage private sector, local, state, regional, and federal partners, as appropriate to the incident, to identify and fill required response roles.

• Task 4: Have or have access to a reporting system.

Strengths


Strength 1: (Region and Clark) The majority of health departments quickly accessed the states standing orders for recommendations.

Strength 2: (Region and Clark) It was identified that ODH maintained a cache of antibiotics that could be requested by locals before the SNS was requested.

Strength 3: (Region and Clark) Epidemiologists were readily available to assist and gather necessary data.

Strength 4: (Clark) Partners very interested in Closed POD and began to create dispensing plans for staff and clients. This included agencies that had residential clients as well as agencies with clients in the community such as Hospice.



Area for Improvement 1: (Region and Clark) Understanding of what the ODH cache is and what it is available for.

Reference: Local SNS and Mass Prophylaxis Plans

Analysis: While ODH does maintain a cache of antibiotics the vast majority of hospitals and local health departments were unaware of its existence, more information needs to be gathered on this resource. Specifically, who is it available too? How much is available?

Area for Improvement 2: (Region and Clark) Requests to pharmacies as dispensing sites and regional Points of Dispensing need much more review.


Analysis: On a national level there has been the initial discussions involving pharmacies dispensing SNS antibiotics as well as the possibility of regional POD sites. Both of these options need much research and review before contemplating their use.

Areas for Improvement 3: (Clark) Closed POD agreements need to be formalized pre-event.




Reference: Local SNS and Mass Dispensing Plans

Analysis: There is great interest from local health care coalition partners and CCCHD needs to be more responsive in a timely manner to put these agreements in place.

Areas for Improvement 4: (Clark) There is a need for more familiarity with the Strategic National Stockpile assets, including what medications should be requested for prophylaxis.

Reference: Local SNS and Mass Dispensing Plans, ODH Standing Orders.

Analysis: Requesting supplies became a challenge when public health was attempting to place an order to cover both treatment and prophylaxis. There may have been some confusion regarding treatment (with initial cases) and then switching to prophylaxis. Additionally, the forms for requesting MCM were outdated in the Clark County plan.

Objective 4: Demonstrate the ability to request, maintain, and track SNS medical materials during a simulated biological incident. (EEG will be used to address hospital request of SNS materials).

The strengths and areas for improvement for each HPP/PHEP capabilities aligned to this objective are described in this section.

PHEP Capability #9 - Medical Material Management and Distribution

• Activity 1: Direct and activate medical materiel management and distribution. • Activity 2: Acquire medical materiel. • Activity 3: Hospital Material Management Planning.

Strengths


Strength 1: (Region and Clark) All local health departments had solid Strategic National Stockpile (SNS) plans in place and were readily available and used during the exercise.

Strength 2: (Region) There was collaboration between some hospitals and local health departments during the SNS requesting process.



Area for Improvement 1: (Region and Clark) Details involved with the requesting process for the SNS.


Analysis: While all locations understood that hospitals and health departments must request the SNS through their county EMA there was a definite need for more specific training for hospitals, health departments and EMAs.




Area for Improvement 2: (Region and Clark) Need for establishing additional closed PODs.


Analysis: Numerous health departments acknowledged that there was a definite need for identifying and establishing additional closed PODs. These would be in place to reduce the number of individuals showing up at general PODs throughout the individual counties; thus lessening the burden on LHDs and improving the likelihood of a larger number of individuals receiving their prophylaxis.

Area for Improvement 3: (Clark) EMA could be utilized more to obtain assets needed to set up PODS or receive material.


Analysis: Better utilizing EMA in this function would free up public health personnel for other necessary tasks.

Objective 5: Demonstrate that processes are in place to request and activate volunteers to support the jurisdictions public health agency’s response during a simulated biological incident.

The strengths and areas for improvement for each PHEP capability aligned to this objective are described in this section.

PHEP Capability #15 – Volunteer Management

• Task 1: At the time of an incident, identify the desired skills and quantity of volunteers needed for the incident from the pre-incident volunteer registration.

• Task 2: At the time of an incident, contact pre-incident registered volunteers using multiple modes of communication.

• Task 3: Determine staffing needs for POD operations.

Strengths

The full capability level can be attributed to the following strengths:

Strength 1: (Region and Clark) Demonstrated that processes were in place for contacting and requesting volunteer resources for assistance during need. In Clark County, the Volunteer Reception Center (VRC) was requested and mentioned in the Volunteer Management Plan.

Strength 2: (Region) Hospitals utilized medical students, volunteers and extra staff to support the response.

Strength 3: (Region and Clark) Planned for the opening of a volunteer reception center to ensure additional volunteers would be available when needed.


The following areas offer improvement to the full capability level already addressed:




Area for Improvement 1: (Region and Clark) Increase number of volunteers available.

Reference: Local Plans and SOPs

Analysis: Multiple locations identified the need to increase the number of volunteers within their organizations to provide support during similar incidents. Look at possible volunteer recruiting opportunities as an option for increasing numbers to pull from during actual incidents.

Area for Improvement 2: (Region and Clark) Identify backups for primary volunteer coordinators.


Analysis: Some locations noted that they did not have a backup to their primary volunteer coordinator and were unable delegate and dispatch volunteers where needed. Identifying a backup will ensure a smooth transition if the primary is unavailable for any reason.

Area for Improvement 3: (Clark) Need to exercise VRC once more


Analysis: United Way has had personnel turnover and exercising the VRC would be beneficial.

CONCLUSION The Chaos and Confusion FE successfully met the established objectives and provided an opportunity for those with a role in response to a biological terrorist incident to apply the actions and resources that would be needed to work collaboratively and share resources and information with local, regional, and State partners. The lessons learned from the exercise will be used to improve planning, coordination, and response to future incidents.

The internal and external coordination that occurred during the exercise confirmed that the stakeholders involved in the exercise are committed to ongoing testing of plans, policies, procedures, and capabilities to assure an effective and coordinated response to any type of incident.

An Improvement Plan (IP) has been included as an appendix to this document. To address the gaps that have been identified, stakeholders should immediately begin taking steps to collaborate on a plan to commence the activities necessary to accomplish recommended improvements, and to continually measure the progress made.


Appendices- Chaos and Confusion June 2017 A-1 Clark County, OH


APPENDIX A: IMPROVEMENT PLAN This IP has been developed specifically for Clark County and CCCHD as a result of Chaos and Confusion conducted on 06/06/2017.

1 Capability Elements are: Planning, Organization, Equipment, Training, or Exercise.

PHEP Capability Issue/Area for Improvement Corrective Action Capability

Element1 Primary

Responsible Organization

Organization POC Start Date Completion

Date

HPP #10 Medical Surge:

1. There is a need across the region for better information to partners about medical surge issues within the hospitals.

Increase PH users by 2 persons (total 4) and increase familiarity with OHTRAC

Training CCCHD EPC 07/01/2017 12/01/2017

PH to better understand how SRMC uses OHTRAC

Planning CCCHD/SRMC EPC 07/01/2017 12/01/2017

2.CCCHD needs increased familiarity with Regional Biological and epidemiology plans

Provide review of Epi plans (local and regional) with Admin Team/PIO and CD teams

Training CCCHD EPI 07/01/2017 12/31/2017

Provide review of Biological plan and how it intersects with local ERP. Audience Admin/PIO and CD

Training CCCHD EPC 01/2018 03/2018






Element2 Primary



Date

HPP# 6 PHEP # 6 Information Sharing

1. Need more robust information sharing plans.

Create and revise procedures

Planning CCCHD EPC 07/01/2017 09/01/2017

Share with CCCHD Staff

Training CCCHD EPC 09/01/2017 01/15/2018

Create a liaison job description within ICS that is specifically responsible for sharing information with partners


2. Struggled to establish battle rhythm

Revise ERP to highlight battle rhythm for information sharing in DOC


3. Animal and Agriculture resources need to be available for consult.

Establish SME resources and include in ERP as a reference

Planning CCCHD Environmental Division

Personnel

07/01/2017 07/01/2018

[Continue adding capabilities and related information as relevant.]






Element3 Primary



Date

PHEP # 8 Medical Countermeasures

1.Learn more information regarding ODH cache and SNS assets.

Attend IMATS Training


Update Mass dispensing plan with new forms for MCM


Attend CDC training for SNS.

Training CCCHD Nursing Supervisor or

designee

07/01/2017 07/01/2018

2. Increase number of closed PODs

Request help from Nursing division to assist in recruiting and formalizing agreements for closed PODS

Organization CCCHD EPC/Nursing Division and Health Care

Partners

07/01/2017 07/01/2018

Attend CDC training for SNS.

Training CCCHD Nursing Supervisor or

designee

07/01/2017 07/01/2018







Element4 Primary



Date

PHEP #9 Medical Material Management and Distribution

Need to increase understanding of requesting process for SNS or mass prophy

Attend IMATS Training


Tabletop exercise with CCCHD group

Exercise CCCHD EPC 07/2017 08/2018

Regional exercise in November 2017

Exercise CCCHD EPC 07/2017 12/01/2017

Yearly training with closed POD partners








Element5 Primary



Date

PHEP #15 Increase # of volunteers Recruit for MRC Organization CCCHD MRC

coordinator 07/2017 07/2018

Increase comfort with VRC concepts

Exercise VRC Exercise CCCHD EMA 07/2017 07/2018





APPENDIX B: EXERCISE PARTICIPANTS Agencies within Clark County who participated in the exercise are highlighted in yellow.

Participating Organizations Coalition Member Type # in Coalition # Participating % Participation

State & Local Government Ohio Department of Health 1 1 100%

Local Health Departments 8 (Regional HCC) 8 100% Champaign Health District Clark County Combined Health District Darke County General Health District Greene County Public Health

Miami County Public Health Public Health – Dayton & Montgomery County

Preble County Public Health Sidney-Shelby County Health Department

Emergency Management Agencies 8 (Regional HCC) 7 88% Champaign County EMA Clark County EMA Greene County EMA Miami County EMA Montgomery County Office of Emergency Management

Preble County EMA Shelby County EMA Mental Health Services 1 (Clark HCC) 1 100% Mental Health Services for Clark and Madison County

Federally Qualified Health Center 2 (Clark HCC) 1 50% Rocking Horse Community Health Center

Board of Developmental Disability 1 (Clark HCC) 0 0% Shelby County Board of DD




Non-government Coalition Members and Partners Hospitals 2 (Clark HCC) 1 50% Community Mercy Health Partners Dayton Children's Good Samaritan Hospital Grandview Greene Memorial Joint Township Hospital Kindred Hospital Miami Valley Hospital Soin Medical Center Springfield Regional Medical Center Upper Valley Medical Center Wayne Hospital Wilson Health Long Term Care Facilities 14 (Clark HCC) 2 14% CRSI Oakwood Village Vancrest of Eaton Vancrest of New Carlisle Vancrest of Urbana Hospice Unsure Hospice of Miami County Hospice of the Miami Valley Ohio’s Hospice of Dayton

Additional Information/Comments

• Ohio EMA Representative was located at the CCCHD exercise location as support and observer.

• Cedarville University representative was located at the CCCHD exercise location as an observer.




APPENDIX C: ACRONYMS AND ABBREVIATED TERMS Acronym Stands for: Notes

AAR/IP After Action Report / Improvement Plan

CCCHD Clark County Combined Health District

CD Communicable Disease

DOC Departmental Operations Center

EMA Emergency Management Agency

EMS Emergency Medical Services

EOC Emergency Operations Center

EPC Emergency Preparedness Coordinator

EPI Epidemiologist

ERP Emergency Response Plan

HICS Hospital Incident Command System

HCP Health Care Provider

HOMV Hospice of Miami Valley

IC Incident Commander

ICS Incident Command System

ILI Influenza Like Illness

LE Law Enforcement

LTC Long Term Care

MARCS Multi Agency Radio Communication System

MHS Mental Health Services of Clark and Madison

MCM Medical Countermeasures i.e. antibiotics for exposure to tularemia

NOS Not Otherwise Specified

Oakwood Oakwood Village

ODH Ohio Department of Health

OEMA Ohio Emergency Management Agency




OPHCS Ohio Public Health Communication System Sends messages by email, text or phone call

PD Police Department As in “Spfld PD” or Springfield PD

PH Public Health

PIO Public Information Officer

POD Point of Dispensing

q every

RHCHC Rocking Horse Community Health Center

S/S Signs and symptoms

SNS Strategic National Stockpile

SOP Standard Operating Procedure

SRMC Springfield Regional Medical Center

Sx Symptoms

Vancrest Vancrest of New Carlisle

VRC Volunteer Receptions Center

Participant Feedback Form Chaos and Confusion Functional Exercise

Rev. April 2013 A- 10 Clark County, OH HSEEP-C09 Homeland Security Exercise and Evaluation Program (HSEEP)

APPENDIX D: PARTICIPANT FEEDBACK SUMMARY PARTICIPANT FEEDBACK FORM FROM JUNE 6 HOTWASH

@ Clark County Combined Health District location Thank you for participating in this exercise. Your observations, comments, and input are greatly appreciated, and provide invaluable insight that will better prepare our region against threats and hazards. Any comments provided will be treated in a sensitive manner and all personal information will remain confidential. Please keep comments concise, specific, and constructive.

Part I: General Information Please enter your responses in the form field or check box after the appropriate selection.

Name: Clark County Group Feedback (5 agencies)

Agency / Organization Affiliation: Clark County Combined Health District; Vancrest of New Carlisle, Mental Health Services of Clark/Madison, Clark EMA, Hospice of Miami Valley

Position Title: submitted by C. Conover- input from multiple participants

Years of Experience in Present Position: ____________________________________

Number of Exercises Previously Participated in: 0 1-5 X 5-10 15+

Exercise Role: Player Facilitator/Controller Observer Evaluator

Location during Exercise: Clark County Combined Health District


Rev. April 2013 A- 11 Clark County, OH HSEEP-C09 Homeland Security Exercise and Evaluation Program (HSEEP)

Part II: Exercise Design Please rate, on a scale of 1 to 5, your overall assessment of the exercise relative to the statements provided, with 1 indicating strong disagreement and 5 indicating strong agreement.

Assessment Factor Strongly Disagree

Strongly Agree

Pre-exercise briefings were informative and provided the necessary information for my role in the exercise. 1 2 3 4 5

The exercise scenario was plausible and realistic. 1 2 3 4 5 Exercise participants included the right people in terms of level and mix of disciplines. 1 2 3 4 5

Participants were actively involved in the exercise. 1 2 3 4 5 Exercise participation was appropriate for someone in my field with my level of experience/training. 1 2 3 4 5

The exercise increased my understanding about and familiarity with the capabilities and resources of other participating organizations. 1 2 3 4 5

The exercise provided the opportunity to address significant decisions in support of critical mission areas. 1 2 3 4 5

After this exercise, I am better prepared to deal with the capabilities and hazards addressed. 1 2 3 4 5




Part III: Participant Feedback 1. I observed the following strengths/improvement areas during this exercise (please select

the capability and applicable element related to the strength/improvement areas):

Strengths/Improvement Areas Core Capability Element Improvement Area:

1) Could public health have role in helping support Crisis Intervention response in this scenario. In house inventory of trained staff more visible

2) Encourage public health familiarity with Regional Biological Response Plan, Epi Response Plan

Strengths: 1) Healthcare Partners playing at CCCHD (Mental

Health Services, Hospice of Miami Valley, Vancrest) have good grasp on their internal responses. Evidence/demonstration of robust plans to lockdown, shelter in place, supply line alternatives, use of corporate assets, etc.

Medical Surge

Planning Organization Equipment Training Exercise

X

X

Improvement Area: 1) Partners (especially healthcare partners) need

more information sharing from the health district: situation updates, etc.

2) Consider: in the public health structure, do we need to plan a specific unit under operations for information sharing?

3) Need more robust information sharing written procedures at CCCHD

4) Need way to quickly formulate FAQ’s and consistent message, based on inquiries received from the public; Communicable Disease will quickly get overwhelmed answering calls. So need to engage other staff

5) Consider: is there a way for CCCHD to post regular updates so partners could go in and get those updates on a regular basis during an incident and response? Or is there an existing structure upon which to share information?

6) Partners want clearer guidance pushed to them on environmental involvement such as clean up, weather impact re: transmission and exposure

Strength: 1) Use of Facebook/Twitter handles

Information Sharing


X

Improvement Areas: 1) Need broader understanding and knowledge base

of SNS volume, characteristics (public health) 2) More closed PODs need to be organized and

agreements completed in advance.

Medical Counter Measures


X




Improvement Areas: 1) Need broader understanding and knowledge base

of SNS volume, characteristics and agency roles in receiving stockpile (public health and healthcare partners including EMA)

Medical Material Management and

Distribution


X

Improvement Area: 1) Could public health have role in helping support

Crisis Intervention response in this scenario. In house inventory of trained staff more visible

2) Alter Volunteer Management Plan with some details about requesting the Volunteer Reception Center (VRC)

Volunteer Management


X

Improvement Area: 1) In the public health DOC: we need Job Action

Sheets 2) Define Scope of Public Health Safety Officer;

does it include info sharing/recommendations to health care partners?

3) Routing info within the DOC is still a need for improvement; need routine “round the room” updates

4) Animal and Agriculture resources need to be available for consult; Partners want this kind of information available from public health

Other (Public Health:

Emergency Operations

Coordination)


X

X

2. Which exercise materials were most useful? Please identify any additional materials or resources that would be useful.

No group conversation on this, but player prep materials well received. In addition, the printed out injects were very nice.

3. Please provide any recommendations on how this exercise or future exercises could be improved or enhanced. 1) Simcell: is there an alternate way to go about this? Multiple failed attempts to call by

many different units/agencies in the room; phone lines being busy may be realistic but if this happened, we would then find an alternate route to communicate with our partners, if it meant getting in the car and driving there. What if we engaged local partners to be the Simcell? They don’t have to commit to playing as an agency, just commit to pick up the phone for 4 hours and provide a response that they would likely give (i.e. law enforcement)

2) Note from C. Conover: Phonebook and registration: agencies were not aware that they needed to “register” again, after they thought they had “signed up” through GDAHA or




me. I could not tell in real time which agencies had registered or not, so I thought all was well until last day before exercise. Larry was great to take my phone call despite many other things he had to juggle day before but as it is info and numbers still were not correct on final copy of phone book. Also, some agencies registered as controllers and not players. I am seriously not trying to say that this challenge is any one person’s responsibility, because it is all of ours; so what could I do to help?

Additional cumulative participant feedback is gathered in a file at Clark County Combined Health District and is available upon request.




APPENDIX E: EXERCISE EVENTS SUMMARY In formulating its analysis, the evaluation team has assembled a timeline of key exercise events. This section summarizes what happened during the exercise in a timeline table format. Focus of this section is on what inputs were presented to the players and what actions the players took during the exercise. Successful development of this section is aided by the design, development, and planning actions of the exercise design team.

Date

Time

Scen

ario

MHS

RHCH

C

Oak

woo

d

SRM

C

EMA

Vanc

rest

HOM

V

CCCH

D

Oth

er

Event/Action

06/0

5/17

X

FBI Fire Line received discussing increased threat of terrorist activity; Increased evidence of security at public events; WPAFB Security Level Bravo

X Suspect mosquito spraying is the mechanism used to disperse an agent. Individuals of suspected terror events apprehended; film of them consulting with specific individuals who are not apprehended. Description available

X Increased surveillance through healthcare and public health systems requested x Case counts of ill persons in Jacksonville, Norfolk, Watertown available; CDC providing a case

definition, case definition shared with providers. Health care providers and all agencies fielding calls; residential facilities are seeing supply shortages threatened.

x SNS being requested in other states. Tularemia confirmed per lab tests. Strain is virulent, has been weaponized; does not have the same characteristics as naturally occurring tularemia

x Simulated shared FBI info with first responders and other partners through email networks x Set up CCCHD DOC

06/0

6/17

0800 X x Reports of increase in persons with local Influenza Like Illness (ILI); ODH lab and OPHCS info received

0808 X x Oakwood contacted CCCHD: 8 people with delirium, UR, fever, 2 more suspect; no swabs

0809 X X RHC Contacted HD: Tularemia info needed; assured Health Alert would be getting to them

0810 x Used Emergency call list to notify staff not to visit Oakwood due to mx with sx. Make sure all staff has PPE; if not, go to office and obtain PPE.

0810 x WPAFB traffic backed up, threat level Charlie and detailed ID checks, avoid area if possible

0810 x Notified staff of office closures in Xenia and other satellite clinics

0809 X X Call to Oakwood: 8 in need of PCR lab; defined suspect case; confirmed no swabs; need to order




Date

Time

Scen

ario

MHS

RHCH

C

Oak

woo

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SRM

C

EMA

Vanc

rest

HOM

V

CCCH

D

Oth

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Event/Action

0810 x Reviewed info on Rabbit fever, texted info to all staff

0820 x All managers notified of update and advised to stay tune to local news station. Notify all patients in areas of situation. Follow q every 1-2 hours. Managers to use text with updates to staff.

0821 x x Oakwood has upset family members; requesting crisis team from MHS. MHS will re-evaluate after LE engaged to take care of active/suspicious mosquito spraying around Oakwood

0827 X X MHS staff member ill from festival (replaced ill staff member on duty): call to find out more info regarding festival; called to SRMC to see if any positive tularemia

0827 x Health Alert released from Comm. Disease Unit; audience: HCP, Urgent Cares, clinics, hospitals 0830 x Media reporting situation and threat as told by Reliable Anonymous Secret Source (fabricated

for exercise- “Anonymous”) 0830 x X From Dayton Children’s: 1 Clark patient in ED: 15 y.o. male s/s of tularemia; call to DCMC: child

serum positive for tularemia no demographics, all sx of Tularemia as probably cause. Entered case in ODRS.

0830 x Info out to all MHS staff; implement screeing procedures for vitals; contact SRMC, stop visitation on inpatient, modified precautions.

0835 x List and patients experiencing s/s and report to HD or EMA. Notify all about protocol; f/up on needs (priority list). Updates to staff

0838 x X X Mental Health and Oakwood contacted CCCHD: There is mosquito spray happening: should they cover (AC) units? who sprayed? PCR tests done x 8; increased sx

0840 x x Vancrest called CCCHD: requested pharmacy and equipment from corporate headquarters; nothing available; staff person ill and isolated; air off/windows closed; self-quarantined; PCR advised

0850 x Calling local pharmacies in area to determine antibiotics and supplies. 0850 x x More info on sick staff member from Vancrest; attended soccer tournament. 0850 x Contacting in house pharmacy for tx of tularemia; some short supply available from in house

pharmacy. 0857 X x Hospice reported to CCCHD: staff member with HA/ fever; attended festival past weekend,

sending home. Strawberry festival : advised testing 0858 x Mental Health Services contacting HD with questions: client reporting suspicious activity; no

symptoms. Discussed S/S of tulermia, not person to person, if sx send to hospital.




Date

Time

Scen

ario

MHS

RHCH

C

Oak

woo

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SRM

C

EMA

Vanc

rest

HOM

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CCCH

D

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Event/Action

0900 x Unable to get ahold of DME supplier 0900 x x Oakwood: 8 swabs positive for tularemia, maintenance sprayed for mosquitos; running out of

meds. Oakwood had received some meds from Kroger, but need more. 0900 x x Call to SRMC for cache and amounts; SRMC has 1 positive for Tularemia and 41 with sx, 0900 x x Call to ODH and advised of meds for Tularemia, advised to go through EMA for pushpack.

Discussed RMRS and regional supply SRMC ordering but needed form. CCCHD ordering through SRMC

0901 x x Safety officer contacting LE about reported threat of tularemia; discussed PPE for law enforcement and ways to keep LE safe. Requested ongoing communication about situation

0902 x x SRMC and CCCHD discussed symptoms and treatment. 0907 x x LE contacting CCCHD requesting prophylaxis for officers. None at this time. watch for

fever/exposure 0910 x x Spoke with Maj. Chris Clark @CCSO: if it is credible terrorist activity and have been alerted by

FBI, it is unsafe to approach. (HD trying to determine proper PPE) Deadly force can be used. 0910 x Updates to staff with news info re: suspects; texted pictures of suspected vehicle 0910 x Crisis hotline established for support (Mental Health?) 0915 x Called ODH for info re: a crisis line; ODH has set up a line #614-555-1234; info relayed to

receptionist and PIO 0915 Xalled RMRS for antibiotics 0916 X All agencies experience “sick” staff members…those with last names beginning with A, B, C 0920 x Staffing issues: changed assignments to cover services 0920 x Surge: notify all staff on one call system that we will have antibiotics available for them and

their families 0925 x 5 nurses/5 SW advised to go to Soin MC 0925 x Public Health Objectives:

1) Engage Law Enforcement to stop spraying. 2) Determine nature and extent of illness. 3) Determine local stockpile regionally

0927 x Determined air purifying respirator to be worn with level C PPE. Attempt to contact LE- unable; called EMA to ask for help in notifying LE.

0930 x x Received call from HD: how do they request SNS? I advised there is a form. Sent. 0930 x x Oakwood Independent living residents with animals concerned called to discuss exposure




Date

Time

Scen

ario

MHS

RHCH

C

Oak

woo

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SRM

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EMA

Vanc

rest

HOM

V

CCCH

D

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Event/Action

usually limited to certain animals 0932 x x In response to a request, MHS notified Oakwood Village: MHS cannot physically send crisis

team to their location. We will set up a team in MHS board room and receive calls and provide assistance.

0935 x Contacted HD regarding suspicious activity: recommend call LE; calling LE 0940 x Call med lab to do PCR testing on 1 staff, 3 clients 0944 x Additional Public Health Objectives:

4) Set up open and closed PODS 5) Request SNS

0945 x x x Oakwood needs doxy; noted fatality; 63 residents with s/s and 17 staff ill. Need meds, discussed pushpack; contacted Hospice to be prepared to assist

0946 x x MHS Visitor with sx sent to ED; visitors now restricted; reviewed not s/s 0950 x x Contacted both GCPH and CCCHD for closed POD 0950 x Arrangement for contacting staffing agencies if needed

0950 x x Visitor with sx, sent away; reviewed not person to person asked to refer those with sx for testing.

0955 x x Confirmed arrangements as a Closed POD 0956 x x SRMC: 1 confirmed case; wants to coordinate with HD to get message out; pts to ED with sx. Call

to SRMC- confirmed #s seen for s/s of Tularemia; askedto call with # of confirmed or positive PCR tests

0958 x SNS requested x MHS has food: 7 day supply for inpatient (MRE’s); Medicine for Inpatient: Madison Avenue will

work with MHS 1000 x Text to staff to update antibiotics (prophy) for staff and PTs 1000 x Dropsite confirmed on OPOD 1000 x Requesting staff surge in the Comm Disease Unit (request to planning 1000 x x Local school: 3 children sick, sent home ILI; discussed s/s and advised no shutdown 1002 x Shared license plate info with LE 1008 x RHCHC Reporting Class A: transported 4 to SRMC and 2 to DCMC; 18 tx but not transported;

several reported park attendance and 1 strawberry festival 1009 x x Hospice: pt with s/s, attended park over weekend; requeted PCR tested; notified Hospice of

other deaths




Date

Time

Scen

ario

MHS

RHCH

C

Oak

woo

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SRM

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EMA

Vanc

rest

HOM

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CCCH

D

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Event/Action

1010 x Safety officer Asked about tularemia in water: lakes, ponds, streams and if deactivated by sunlight

1010 x x Fire asking for Prophylaxis- responded working on it 1010 x Call to ODH for countermeasures/PEP for first responders and critical infrastructure; advised IC

to decide critical infrastructure but can prophy/PEP 1015 x Advised staff that exposure widespread; all to wear PPE or at least masks 1015 x Info to local parks upon their inquiry. Using EMA as liaison to local parks, due to difficulty

contacting parks directly 1015 x Set up child care for staff with small children who can come to work; used 1 call system to

communicate 1025 x Follow up with HD re: closed PODS ending 1025 x Fielding questions about white powder in car rental company x MHS notified staff regarding antibiotics to be distributed to staff members and family as a

Closed POD; working on antibiotic distribution plan; Cipro is OK for pregnant staff members 1025 x x EMA contacted to request VRC 1030 x Ordering/Requesting equipment for unloading push pack 1040 x EMA sent 12 hr. push pack to OEMA 1044 x x VRC Request form provided to CCCHD from EMA 1052 x x Received information from ODH that SNS would arrive in Clark in 2.5 hours; info to HD

1100 x Continue fielding questions from suspected exposed persons 1100 x Ordering refrigerated trucks/units for deceased; requiring mx calls 1105 x x Discussion with SCAT: Buses and drivers for PODS; but requesting treatment for drivers 1110 x x Contacted United Way for VRC; will open at 10 PM 1110 x Media noting scattered reports that people are crowding into stores, looting/fighting. 1115 x Event planner: asking should she cancel outside event, what is exposure from contaminated

objects? Discussed bleach cleaning 1122 x Planning for closed POD initially 1130 x Shelter in place due to suspicious activity 1130 Received request for additional cold storage; UHF radios to HD 1142 x Secured 4 refer trailers for dead body storage NOS x x Communicated with SRMC over MARCS Social media injects throughout


Appendices- Chaos and Confusion June 2017 A-20 Clark County Ohio


APPENDIX F: OPHCS MESSAGE REPORT The Ohio Public Health Communication System (OPHCS) must be integrated into all functional and full scale exercises conducted before during and after and exercise. Uses can include notification of exercise, situational awareness, and end of exercise. Included here is the OPHCS Message Report.




CCCHD Vancrest

Mental Health Oakwood

Rocking Horse Clark EMA

SRMC Rocking Horse Hospice of MV




APPENDIX G: ICS FORM 205 This ICS 205 form documents the incident radio communication plan utilized during the exercise.

1. Incident Name: Tularemia Exerise (Chaos and Confusion)

2. Date/Time Prepared: Date: 6/6/2017 Time: 1000

3. Operational Period: Date From: 6/6/2017 Date To: 6/6/2017 Time From: 0800 Time To: 1200

4. Basic Radio Channel Use:

Zone Grp.

Ch # Function

Channel Name/Trunked Radio System

Talkgroup Assignment RX Freq N or W

RX Tone/NAC

TX Freq N or W

TX Tone/NAC

Mode (A, D, or M)

Remarks

1 1 Monitor for Situational Awareness

XClark R. Holbrook Received Test message from ODH

2 Monitor for Situational Awareness

XLDH-WCEN Jodi Wood

2 1 Monitor for Situational Awareness

XLDH- WCEN Jan Walker

5. Special Instructions:

6. Prepared by (Communications Unit Leader): Name: R. Holbrook Signature: Signed by Rick Holbrook

ICS 205 IAP Page Date/Time: 6/6/2017 12:00 AM




APPENDIX H: ADDITIONAL EXAMPLE DOCUMENTATION CREATED DURING EXERCISE




APPENDIX I: STRENGTHS AND OPPORTUNITIES BY PERFORMANCE AREAS

Many strengths and improvements can be

categorized in more than one area.

Strength = Cumulative Strength Noted from Exercise Improvement = Cumulative Area for Improvement Noted from Exercise S = Strength identified by Individual Feedback; I = Area for Improvement identified by Individual Feedback

Notification • (Strength): (Region) multiple hospitals established triage areas outside of the hospital to assist with influx of patients and to limit what was hitting their Emergency Departments.

• (Strength): (Region and Clark) Epidemiologists were readily available to assist and gather necessary data.

• (Improvement): (Clark) Closed POD agreements need to be formalized pre-event. • (Strength): (Region) There was collaboration between some hospitals and local health departments

during the SNS requesting process. • (I) Need better info sharing; partners need more notification from CDC, local public health, etc. • (S) OPHCS worked! • (I) Scheduling of regional public health conference calls cannot be done by email

Safety and Security • (Improvement): (Clark) Information did not always flow well within the public health DOC. • (S) Safety officer seemed very involved; very knowledgeable • (I) Law enforcement involvement in the exercise could have been beneficial • (I) Need a detailed explanation of job duties in ICS response • (I) Consider Safety of staff, our offices, staff, panic button, lock door, deliver meds

Utility System (If applicable: generators,

IT, etc.)

• (Improvement): (Region) There were multiple sites complaining of communication issues where phone lines did not roll over and radio use was causing computer issues.

• (I) Mental Health Services to develop in-house building notification phone tree for emergencies • (I) Need to consider how to back up our EMR • Paper forms, satellite radio • (I) Slow moving technology makes communication difficult




Communication • (Improvement): (Region and Clark) There is a need across the region for better information to partners about medical surge issues within the hospitals.

• (Strength): (Region) Regional health commissioner’s conference call was completed within the first hour ensuring all local health departments were operating from the same information.

• (Strength): (Region and Clark) Redundant interoperability using MARCS radios was established early between hospitals and local health departments during the exercise.

• (Strength): (Region and Clark) Health Alert Network (HAN)/ OPHCS was used to get key incident response information to partners.

• (Strength): (Clark) EMA was able to assist with information sharing to partners particularly in acting as a liaison with Law Enforcement.

• (Improvement): (Region and Clark) It was observed at multiple locations that information was not being readily shared with all partners dealing with the response.

• (Improvement): (Region and Clark) There was confusion on messaging concerning SNS assets and the cache maintained by ODH.

• (I) Section and command staff leaders need routine briefings • (I) Continuity of Operations: Key players were eliminated, so unsure how to proceed; Share extensive

understanding of aspects of response so that positions can be manned even with loss of employees • (I) Communicating current objectives needing to be addressed • (I) providing detailed info to allow all responders to be informed and carry out their tasks • (I) Partners need more reputable communication and more often; updates would be good; Possibly a

central site for information and situational awareness • (I) Do more regular “battle rhythm” entire room briefings; hourly, etc. • (S) Opportunity for OPHCS and OPOD was good. I feel prepared to deal with them again for now

Command Structure (This is not considered a critical area according to

The Joint Commission, but has been included as a point of emphasis based on previous exercises)

• (Strength): (Region) Numerous locations identified that IC within HICS/DOC provided situational update on hourly basis.

• (Strength): (Clark) Good success and evidence of use of ICS forms, particularly for communicating general messages and closing circle for resolution. Forms utilized included ICS 214, 213 RR, 213, 205, 206, etc. See Attachments.

• (Strength): (Region and Clark) All local health departments had solid Strategic National Stockpile (SNS) plans in place and were readily available and used during the exercise.

• (Improvement): (Region and Clark) Need for establishing additional closed PODs. • (Strength): (Region) Hospitals utilized medical students, volunteers and extra staff to support the

response. • (I) Change of staff confusing/ change of roles • (I) Staff update meeting needed once an hour or so; There wasn’t a good structure set up where all the

commands meet together to ensure on the same page • (I) Better understanding for the group of when to go into ICS- prior to this react as a normal response. • (S) Mental Health Services demonstrated planning to set up in-house crisis center in board room for

incoming calls of concern and identify staff to man the calls




Management of Cases or Patients

• (Strength): (Clark) Health care organizations in Clark County demonstrated robust agency level responses from Healthcare Organizations playing in Clark County (i.e. shelter in place, lockdown, supply line alternatives, use of corporate assets.)

• (Strength): (Clark) Hospice and Mental Health Services demonstrated plans to support other partner agencies by providing additional services as part of the community’s response due to multiple deaths.

• (Strength): (Clark) Partner Healthcare Organizations communicated frequently with Communicable disease unit regarding individual case information. This is evidenced by documented 213 and 214 forms created during the exercise. This strength is separate from the gap noted in areas for improvement, which speaks to situational awareness.

• (Strength): (Clark) Partners very interested in Closed POD and began to create dispensing plans for staff and clients. This included agencies that had residential clients as well as agencies with clients in the community such as Hospice.

• (I) Mental Health Services to work with SRMC for process for medical clearance for suicidal patients during disaster

• (S) Hospice: Each RN has a number of patients they are assigned to – responsible to keep informed and assess and deliver ATB

Resources • (Improvement): (Region) Kindred hospital was overlooked as a resource for freeing up inpatients from other hospitals.

• (Improvement): (Clark) Animal and Agriculture resources need to be available for consult; partners expect this kind of information from public health.

• (Improvement): (Clark) EMA could be utilized more to obtain assets needed to set up PODS or receive material.

• (Improvement): (Region and Clark) Demonstrated that processes were in place for contacting and requesting volunteer resources for assistance during need. In Clark County, the Volunteer Reception Center (VRC) was requested and mentioned in the Volunteer Management Plan.

• (Strength): (Region and Clark) Planned for the opening of a volunteer reception center to ensure additional volunteers would be available when needed.

• (Improvement): (Region and Clark) Increase number of volunteers available. • (Improvement): (Region and Clark) Identify backups for primary volunteer coordinators. • (Improvement): (Clark) Need to exercise VRC once more • (S) 213 RR preferred over 215 for resource management • Due to simulation cell limitations, unsure how resources would play out (paraphrased) • (I) Use EMA in resource management when appropriate • (S) Was able to discuss getting supplies for “PODS” • (I) Need breakdown of staff needs in PODS. • (I) need more staff • (I) Hospice:13 counties we cover for resources




Staff Knowledge • (Improvement): (Region) Delay with some hospitals dealing with in-patient units assessing potential discharges and transfer out of hospital.

• (Improvement): (Clark) Need increased familiarity with the regional biological and epidemiology plans. • (Strength): (Clark) In review of exercise documentation, there was evidence of research and outreach

regarding safety of responders both internal to CCCHD and external such as first responders. This is in line with the Public Health Preparedness capabilities. In example, the type of PPE and disinfection processes for tularemia were available due to research to establish a known profile of the biological threat.

• (Strength): (Region and Clark) The majority of health departments quickly accessed the states standing orders for recommendations.

• (Strength): (Region and Clark) It was identified that ODH maintained a cache of antibiotics that could be requested by locals before the SNS was requested.

• (Improvement): (Region and Clark) Understanding of what the ODH cache is and what it is available for. • (Improvement): (Region and Clark) Requests to pharmacies as dispensing sites and regional Points of

Dispensing need much more review. • (Improvement): (Clark) There is a need for more familiarity with the Strategic National Stockpile assets,

including what medications should be requested for prophylaxis. • (Improvement): (Region and Clark) Details involved with the requesting process for the SNS. • (I) Newer staff had a lot of questions to ask; Cross Divisional Training would be a good way to answer

those questions • (I) Public Health Staff had no job action sheets; need specific delegated tasks • (I) Set up hourly communication notice process for staff • (S) Knowledgeable staff in Communicable Disease • (I) Need to educate community partners’ staff of large scale incident

chaos and confusion regional functional exercise€¦ · 4. (clark) there is a need for better...

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