Operation PREP November 15 th , 2006

1. Operation PREPNovember 15th, 2006 New England Center for Emergency Preparedness Dartmouth Medical School

2. Overview • Introduction and Background • Exercise Objectives • Activities and Observations • Reactions and Lessons Learned • Recommendations • Conclusions, future directions

3. Introduction and Background • Cooperation of multiple organizations is key to a successful disaster response. • In a disaster, organizations that don’t often work together will have to. • Practice will ensure this collaboration and cooperation are effective • Hanover/Lebanon Region, Wednesday, November 15th, 2006: Functional exercise to practice cooperation of multiple partners

4. Partners • Town of Hanover • City of Lebanon • Dartmouth-Hitchcock Medical Center (DHMC) • Dartmouth College • Northern New England Metropolitan Medical Response System (NNE MMRS) • New England Center for Emergency Preparedness (NECEP)

5. Hospital Objectives Demonstrate: • Ability to respond to an infectious respiratory disease epidemic • Critical ICS sections • Ability to communicate both internally and externally • Ability to coordinate with senior leadership at DHMC • Ability to secure the facility set up external triage at the Emergency Department

6. Hospital Objectives Demonstrate: • Ability to track patients using HC Standard • Decision-making process for requesting community ACC • Ability to identify patients to discharge or transfer to ACC in order to create hospital surge capacity • Decision-making process for transfer of 25 patients to community ACC • Ability to vaccinate health care workers to allow continuity of care in an infectious disease outbreak situation

7. Community Objectives Practice: • Setting up an Emergency Operations Center and implementing Incident Command Structure • Communicating with hospitals and State agencies • Setting up an Acute Care Center (ACC) • Admitting 50 patients to the ACC • Tracking these 50 patients using new software: Health Care Standard (HCS) for patient tracking and Athenahealth for Electronic Medical Records

8. Activities and Observations Hospital Objective: Demonstrate ability to respond to an infectious respiratory disease epidemic • Tested implementation and functionality of the Epidemic Respiratory Infection Readiness Plan. • An All Hazards plan should be developed to fit all events. • Individual department plans exist, but are not collated into an all-hazards plan • ICS staff should be flexible about how they use the plans.

9. Activities and Observations Hospital Objective:Demonstrate critical ICS sections • First time DHMC has used ICS in functional exercise. • Majority of staff in the EOC felt they understood the chain of command, and felt confident in their ability to fulfill their role. • Excellent staff turnout at the EOC • For effective decision-making in the EOC, only key staff should participate in conversations with the IC. Diagram Source: www.fema.gov

10. Activities and Observations Hospital Objective:Demonstrate ability to communicate both internally and externally; ability to coordinate with hospital senior leadership • Phone lines in the EOC were functional • Cell phones were not always operational • Email was used extensively for internal communication. • HANs had to be redistributed as only one member of staff was registered to receive them • Patient tracking software worked well for internal and external communications. • DHMC needs to incorporate a centralized emergency communications plan in their EOP.

11. Activities and Observations Hospital Objective:Demonstrate ability to secure the facility and establish external triage at Emergency Department • ED staff assigned by the EOC went outside to assess and triage the patients on the bus. • Patients were not allowed into the building in order to avoid potential contamination. • Identified need for specific instructions and protocol for establishing an external triage area during an infectious disease outbreak.

12. Activities and Observations Hospital Objective:Demonstrate ability to track patients • Entering the patients into the patient tracking system paralleled assessment of patients in the triage area. • HC Standard and current patient admitting system would need to be linked to avoid duplication of effort and be effective in a real event. • It did not appear that the patient tracking system would severely interfere with the flow of patients. • athenahealth was not tested at DHMC triage location as planned.

13. Activities and Observations Hospital Objective:Demonstrate decision-making process for requesting an Acute Care Center (ACC) • Discussion of how to best utilize this facility • Decided to transfer all infectious Morbus patients to the ACC as a temporary isolation facility for further observation • Goal: cohort and observe these patients until it could be determined if they were sufficiently ill to require critical care, and minimize exposure of staff and other patients. • Decision-making process in this area was efficient, sound and very effective. • The IC discussed the possibility of using another facility as a clean facility for transferring non-infectious inpatients to create additional hospital surge capacity. • Protocol for requesting community assistance for medical surge is not included in hospital emergency response plans at this time

14. Activities and Observations Hospital Objective:Demonstrate ability to identify patients to discharge or transfer to ACC in order to create hospital surge capacity • Identified more than 60 inpatients for immediate discharge • Established a discharge center to immediately open necessary beds • Incident Commander cancelled elective procedures for the day; procedures scheduled for the following day were put on hold until further notice • Hesitant to cancel all procedures due to financial implications • All patients in one inpatient unit were moved to other areas of the hospital so that this unit could become an internal cohort unit if necessary

15. Activities and Observations Hospital Objective:Demonstrate ability to transport 25 patients to community ACC • Physical transfer was not tested. • Discussion about how to transfer them to the ACC, including the possibility of instructing patients to drive themselves there. • Led to an in-depth discussion of liability on the part of the hospital and the need to treat and stabilize arriving patients. • Incident Commander did not want to tie up the ambulances transferring stable, non-critical patients. • Decided to stop running local transportation company shuttles and use those busses to transfer Morbus patients to the ACC. • Patients would be accompanied by staff members from Security and the Emergency Department. All staff on the bus, including the driver, were instructed to wear appropriate personal protective equipment (PPE).

16. Activities and Observations Hospital Objective:Demonstrate ability to vaccinate health care workers to allow continuity of care in an infectious disease outbreak situation. • Three 12-hour vaccination clinics where employees were provided the seasonal flu vaccine at no cost • Advertised to staff via the intranet • Participation was encouraged by department directors. • Clinics were patterned after the New Hampshire POD planning guidance. • 2,890 employees were vaccinated • Average wait time of one minute. • A much larger number of employees could have been managed with the same level of staffing if necessary.

17. Results and Reactions - Hospital DHMC exercise participants demonstrated the capability to: • Initiate specialty teams within the ICS that were able to think and act independently, helping to address organization and community response. • Communicate with the NH DHHS on the phone, with hospital senior leadership through in-person briefings, and with hospital employees through email. • Create hospital surge capacity by transferring and discharging stable patients. • Utilize community medical surge capacity resources to maintain hospital capacity for critically ill patients. • Identify local transportation resources which could be used to move large numbers of patients in a safe and efficient manner. • Vaccinate large numbers of health care workers to maintain continuity of operations in an infectious disease outbreak.

18. Results and Reactions - Hospital Major areas for improvement: • Further training in ICS would be beneficial • Desire to be collaborative will impede decision-making process in real event • Newly released HICS IV • Emergency response plans need to be refined for flexibility, completeness • Useful in all emergency situations • Cover all bases: communication, transportation, surge capacity

19. Activities and Observations Community Objectives: Practice setting up Emergency Operations Center and implementing Incident Command Structure. Practice communicating with hospital and State. • Hanover emergency planners set up EOC in new location – what to bring? • Practice with ICS – not all familiar with chain of command • Job Action Sheets and diagram assisted ICS set-up • Communication: cell phones, landlines, internet – did not test radios

20. Activities and Observations Community Objectives: Practice ability to track 50 patients in a POD • SNS resource tracking requirement • Efficiency: <1 minute per patient • Accountability: full record for each patient

21. Activities and Observations Community Objectives:Practice setting up an Acute Care Center • Multiple organizations: NNE MMRS NH Strike Team, HFD • Besides Hanover FD, none of these people had ever worked together before • Determine ICS – Job Action Sheets and diagram helpful • Physical set up of Cabela’s cots – Supplied by Hanover • Receiving and unloading of medical supplies from DHMC • Secure facility

22. Leverone Field House

25. Activities and Observations Community Objectives:Practice admitting 50 patients to ACC • Local High School and Dartmouth students volunteered as “patients” • No acting – each received a patient card with a description of symptoms • Strike team admitted patients • No patient care given • Written orders to track activities, use of staff and supplies

27. Activities and Observations Community Objectives: Practice tracking 50 patients in ACC using patient tracking and electronic medical records software • Patients given tag with bar code at triage (ED, NEHC) • Scanned at every point of contact – discharge facility, transfer, receiving • Handheld scanners (HCS) are multipurpose tool • HCS linked to WebEOC, monitors anything and everything • Athena tracks care given, resources used

28. Results and Reactions - Community • Strike team worked well together, especially considering they have never done so before this exercise! • Need some non-medical personnel at the ACC to handle administrative and custodial duties • Need simple instructions on how to set up an ACC; very few people know exactly how to do it!

29. Results and Reactions - Community • Supplies are a big issue: how do we get the supplies to the people who need them? • DHMC coordinated the supplies they sent with the Logistics Trailer inventory • State Logistics Trailer was unavailable for the exercise • Pre-printed admission and discharge forms

30. Results and Reactions - Community • Clear lines of communication between State, local and hospital EOC’s, and ACC are a must • Not always clear who should call which organization for what information • Periodic practice and training in ICS and review of emergency response plans will make this process more familiar and comfortable during an actual incident

31. Recommendations • Planning • DHMC should review current emergency response plans, and ensure they are flexible enough to be useful during a public health emergency. • DHMC should develop annexes to this plan, including an emergency communications plan, and mass transportation. • DHMC should review medical surge capacity plans and protocol for requesting assistance from the community. • NNE MMRS should review the ACC Concept of Operations document in relation to NIMS and HICS guidance to ensure compatibility.

32. Recommendations • Operational • Additional education and practice in ICS is needed by both DHMC staff and the NH Medical Strike Team. • Before any IT systems are used, staff will require extensive training in them. Just-in-time training should be created where appropriate.

33. Recommendations • Training and Education • NNE MMRS should continue to educate medical strike team members on ICS and procedures for opening and operating an ACC. • DHMC should continue to education staff on ICS, emphasizing new HICS IV guidance

34. Recommendations • Future Exercises • Additional exercises should exercise other components of hospital and community surge capacity, including staff shortages, and supply use. • Incorporate additional partners and stakeholders in future exercises, including those from neighboring states.

35. Conclusion • Collaboration is key to success • Fire, police, emergency managers, hospital, EMS, local physicians and nurses, nursing home facilities, Visiting Nurses Association, schools, businesses • Supplies • What do you have? • What do you need? • How can you get it? (Hint: be creative) • Practice makes perfect!

36. Resources • NNE MMRS: www.nnemmrs.org • Guidance for planning exercises and drills, medical surge capacity documents, including ACC Concept of Operations • NECEP: http://dms.dartmouth.edu/necep • Department of Homeland Security: www.dhs.gov • Centers for Disease Control: www.cdc.gov • Department of Health and Human Services: www.dhhs.gov • Contact: Reiley Lewis MPH New England Center for Emergency Preparedness Colburn Hill, HB 7462 One Medical Center Drive Lebanon, NH 03756 Office: (603) 653-1189 Reiley.S.Lewis@Dartmouth.edu