2014 Phase III: Tabletop Exercise

1. 1 2014 Phase III: Tabletop Exercise

2. 2 • The 2014 Statewide Medical and Health Exercise is sponsored by: • California Emergency Medical Services Authority • California Department of Public Health • In collaboration with: • California Hospital Association • California Association of Health Facilities • California Primary Care Association • Governor’s Office of Emergency Services • Response partners representing local health departments, emergency medical services, public safety and healthcare facilities

3. Welcome and Introductions • Introduction of Exercise Planners and Facilitators • Introduction of Participants, Subject Matter Experts, Department Officials and Media • Housekeeping Issues • Agenda Review

4. Exercise Purpose To evaluate current response concepts, plans, and capabilities related to a pediatric/medical surge of patients from a contagious disease outbreak in the local community. The exercise will focus on the coordination of medical surge capabilities among community healthcare and response partners.

5. 2014 Statewide Medical and Health Exercise Target Capabilities Operational Communications (formerly Communications) Public Health and Medical Surge (formerly Medical Surge) Operational Coordination and On-Site Incident Management (formerly Emergency Operations Center Management) Public and Private Services and Resources (formerly Volunteer Management and Donations)

6. Exercise Customization Yellow font color signifies the need for customization by the organization/agency and can be deleted after editing at the local level. The tabletop exercise may be customized to include discussion of Operational Area and discipline specific issues, policies and procedures, new equipment or training, and gaps in planning. Some on the information on the following slides is bulleted and the full description that can be read is in the Situation Manual and the Instructor Notes under the slides.

7. Tabletop Exercise Objectives Capability: Operational Communication (Formerly Communications) • Assess the communications process internally and externally, based on local policies and procedures. • Review redundant communication modalities within and across response partners.

8. Tabletop Exercise Objectives Capability: Public Health and Medical Surge (Formerly Medical Surge) • Determine strengths and weaknesses in activation of medical and health partner’s surge plans, focusing on pediatric populations. Identify critical issues and potential solutions.

9. Tabletop Exercise Objectives Capabilities: Operational Coordination and On-Site Incident Management (Formerly Emergency Operations Center Management) • Identify the process to activate the Incident Command System in response to an emerging infectious disease. Determine specific levels necessary based on scenario and local policies and procedures. • Identify the steps in developing an Incident Action Plan and conducting associated briefings. Medical and Health partners provide situation information as requested by the MHOAC Program for situation reporting.

10. Tabletop Exercise Objectives Capabilities: Operational Coordination and On-Site Incident Management (Formerly Emergency Operations Center Management) • Identify the processes for medical and health partners to provide current situational information to the MHOAC program. • Examine the MHOAC program’s process to develop and submit Medical Health Situation Reports consistent with the EOM.

11. Tabletop Exercise Objectives Capability: Public and Private Services and Resources (Formerly Volunteer Management and Donations) • Identify the process for medical and health partners across the response system to request, distribute, track, and return medical countermeasure resources, including scarce resources, consistent with the EOM. • Validate the processes in place to activate the local disaster medical volunteer system.

12. Resources to assist withExercise Customization Response specific information and guidance may be accessed through subject matter experts including, but not limited to: • Neonatal and Pediatric Subject Matter Experts • Medical and Health Operational Area Coordinator Program • Mutual aid coordinators for medical, health, law enforcement and fire services • Communication partners (Include those resources for your exercise on this slide)

13. Options for Exercise Customization Examples of Customization Include: • Address how your community adapts to a sudden need for medical care and hospitalization among a pediatric population • Address how your local health department would coordinate resource needs among the healthcare response community at large

14. Exercise Ground Rules • Do not fightthe scenario • Assume the scenario is real and may impact the jurisdiction and the participants • Participate in a collegial manner: share policies, plans and practices that may benefit others

15. Exercise Ground Rules • Be respectful: allow others to speak and finish their statements • Follow communications etiquette: turn off cell phones, smart phones, computers and any other electronic data equipment

16. Neonatal/Pediatric Needs The following five slides are for background information and are optional.

17. Who is the Pediatric Patient? • Neonate: 0-30 days old • Infant: 30 day-12 months old • Toddler: 1-4 years old • Pediatric patient: < 15 years of age

18. California’s Pediatric Population • Males: 4,725,198 (2012) • Females: 4,515,021 (2012) • 356,000 reside in single parent homes • 309,000 live with a grandparent(s)

19. Pediatric Disaster Considerations Consider the unique needs of newborns, NICU patients, and all pediatrics in disaster planning • Challenges in airborne isolation • Medication and vaccine availability for pediatrics and dosing requirements • Appropriate pediatric nutrition • Daily pediatric supplies of diapers and bottles

20. Pediatric Disaster Considerations • Compile a list of experts in pediatric infectious disease care for Command Center resource • Pediatric movement between tertiary centers and basic facilities for best utilization of pediatric resources and pediatric patient movement issues • Children may present unidentified and without a parent or legal guardian • How will you identify and reunite them?

21. Pediatric Disaster Considerations • Consider environment of care issues related to age • Safety hazards such as uncovered electrical outlets • When possible, keep parents or legal guardians with children • Challenge in physician admitting privileges for children 14 and under (malpractice issue) • Child life support/behavioral health resources and needs for children

22. MERS-CoV Background The following five slides are for background information and are optional.

23. Background – MERS-CoV Definition: a viral respiratory illness, caused by a new coronavirus called “Middle East Respiratory Syndrome Coronavirus” (MERS-CoV) • First reported in Saudi Arabia in 2012 • As of 5/2/14, there are 189 confirmed cases and 82 deaths • Coronaviruses are common viruses causing upper respiratory tract infections in humans and animals • SARS is a well-known coronavirus • First MERS-CoV case reported in the United States 4/24/14

24. Background – MERS-CoV Symptoms: severe acute respiratory illness with symptoms of fever, cough, and shortness of breath • About 50% mortality • Some cases have mild respiratory illness Transmission: between people in close contact. • Positive transmission from infected patients to healthcare personnel • Clusters of cases in several countries are being investigated

25. Background – MERS-CoV Source: not certain, likely from animal source • Camels and a bat have tested positive Diagnosis: PCR testing available at state public health labs and CDC • Respiratory tract specimens, stool • Serology available at CDC Treatment: Supportive care; no specific treatment

26. Case Definition • Fever (>38C or 100.4F) and pneumonia or acute respiratory distress syndrome; and either • Fever (≥38oC, 100.4oF) and pneumonia or acute respiratory distress syndrome; and either • History of travel from countries in or near the Arabian Peninsula within 14 days before symptom onset; or • Close contact with symptomatic traveler with fever and acute respiratory illness (not necessarily pneumonia) within 14 days after travel from countries in/near Arabian Peninsula; or • Member of a cluster of patients with severe acute respiratory illness (e.g. fever and pneumonia requiring hospitalization) of unknown etiology in which MERS-CoV is being evaluated

27. Case Definition - Confirmed/Probable Confirmed Case – A person with lab confirmation* of MERS-CoV infection Probable Case - A patient under investigation with absent or inconclusive lab results for MERS-CoV infection who is a close contact of a lab-confirmed MERS-CoV case *Lab confirmation requires a positive PCR on at least two specific genomic targets or a single positive target with sequencing on a second http://www.cdc.gov/coronavirus/mers/case-def.html

28. Tabletop Exercise The exercise consists of 3 modules plus an addendum for planning the November 20, 2014 Functional Exercise • Each module will identify key issues followed by questions for discussion • Participants are encouraged to share their plans, policies, strengths and gaps as identified in the Organizational Self Assessments

29. Tabletop Modules • Module 1: Operational Communication and Pediatric Medical Surge • Module 2: Operational Coordination and On-Site Incident Management • Module 3: Public and Private Services and Resources

30. Scenario November 2014: Influenza season has begun. Hospital emergency departments and primary care providers throughout (Organizations/ Jurisdiction can fill in location)are seeing an increase in the number of influenza-like illness (ILI) cases. A family of 5 presents to the busy emergency department (ED) with symptoms of influenza-like illness (ILI)

31. Family Members • Dad reports 5 days of fever, cough and shortness of breath. Mom and three kids report 2 days of similar symptoms. The full description can be read from the Instructor Notes in the slides or from the Situation Manual. • The 3 year old’s chest x-ray shows pneumonia; he is hospitalized, receives antibiotics and fluids and is discharged home the next morning • The others are instructed on supportive care and discharged

32. Module 1: Operational Communication and Pediatric Medical Surge Key Issues: • Internal and external communication between key response partners • Use of redundant communication modalities • How do you plan for an influx of pediatric patients? What can healthcare partners not serving pediatric populations do to assist with medical surge from other facilities?

33. Questions for Discussion(Jurisdictions can edit which questions they want to include) • What is your process for receiving and disseminating critical information internally and externally with government and non-government partners? • What redundant communication systems are in place in case of system overload or failure and how are they tested? • How do you provide situation information as requested by the MHOAC Program for situation reporting? • What format and process is used from the California Public Health and Medical Emergency Operations Manual in submitting your situation reports to the MHOAC Program?

34. Questions for Discussion • How does your organization/jurisdiction participate in a Joint Information System? • How would you share your organization’s information with the Joint Information System? Who approves information to be shared? • How does your organization/agency use social media to disseminate information?

35. Questions for Discussion • How do you plan for, and respond to, an influx of pediatric patients during a medical surge? What specific needs have you identified for pediatric surge events? (Staff/Equipment/Supplies/Medications, etc.) • How do non-pediatric acute care facilities respond to pediatric surge when pediatric specialty receiving centers are either overwhelmed or unavailable? • How do healthcare facilities that do not serve pediatric populations, such as some long-term care facilities, assist the community’s and healthcare partner’s surge needs?

36. Module 1Discussion Report Back

37. Scenario (continued) • Two days later, the family presents to another ED with worsening symptoms and developing pneumonias • The father is admitted with pneumonia • The 3 year old is again admitted, this time to ICU and is intubated • The Father’s history reveals travel to Dubai with 15 businessmen from California 10 days before onset of symptoms, and on to Germany for 2 days then home.

38. Scenario (continued) • Due to the dad’s symptoms and travel his physician notifies the local health department and collects specimens for Middle East Respiratory Syndrome – Coronavirus (MERS – CoV) in addition to routine respiratory pathogens • The local health department initiates contact tracing and identifies several sites where the family has had close contact with others

39. Module 2: Operational Coordination and On-Site Incident Management Key Issues: • Response is coordinated through the use of Incident Command System principles and Command Centers/Emergency Operations Centers • Incident Action Plans are developed to guide and document the response and recovery phases • Provide situation reporting as requested by the MHOAC Program utilizing the California Public Health and Medical Emergency Operations Manual format and process

40. Questions for Discussion(Jurisdictions can edit which questions they want to include) • How does your organization/jurisdiction implement Incident Command System principles to organize and guide response and recovery operations in an emergency? Does the use of Incident Command System principles address, when necessary, the application of unified command? • How is your Command Center/Emergency Operations Center activated to support Incident Command System operations? Does the activation process utilize a written plan?

41. Questions for Discussion • How are key partners notified of activation? What time frame is the notification communicated in? • How does your organization/jurisdiction communicate and share information with other members of the incident management team or Command Center/Emergency Operations Center personnel? Is there a policy and procedure that covers this? If procedures are in place, is the process regularly tested?

42. Questions for Discussion • What action planning procedures and forms are used to document and guide the response and recovery process? Is the Incident Action Plan shared with response partners in the jurisdiction? • How are requests made or responded to for situational reporting utilizing the California Public Health and Medical Emergency Operations Manual?

43. Questions for Discussion • What is the operational area plan during a pediatric medical surge? How does the plan address mutual aid? How does the plan coordinate from the operational area to the regional level to the State level?

44. Module 2Discussion Report Back

45. Scenario (continued) Emergency Departments and community health centers are seeing a definite rise in numbers of influenza-like illness (ILI) cases and admissions have increased over 10% with acute respiratory illnesses, including a large influx of pediatric patients ages 2-16 years (Organizations/ Jurisdictions can fill in number or change the percentage to meet exercise testing needs for the area)

46. Scenario (continued) • Two days later, CDPH and CDC labs confirm MERS-CoV in all members of the family and multiple contacts • With MERS-CoV confirmation, high mortality in other countries, and intense media coverage, people with ILI are flooding the healthcare system

47. Scenario (continued) • The local health department sends out a Health Alert/Advisory to notify students, teachers and employees of the possible exposure and instruct them to seek medical care if they have ILI symptoms • The local health department identifies and contacts those with close contact/exposure • Many close contacts have ILI symptoms and are tested for MERS-CoV; >50% of the contacts tested are positive and many have been hospitalized

48. Module 3: Public and Private Services and Resources Key Issues: • Identifying needs in a pediatric surge event • Requesting, distributing, tracking and returning materials and medical countermeasure resources • Activating local disaster medical volunteer systems

49. Questions for Discussion(Jurisdictions can edit which questions they want to include) • How do you identify your human and material needs in a pediatric surge event? • How do you request, distribute, track and return medical countermeasure resources in accordance with the EOM, to include allocation of scarce resources? • What mutual aid agreements are in place? • How is the local disaster medical volunteer system activated? What are the triggers to activating the system?

50. Module 3Discussion Report Back