contents · web viewsituation manual (sitman) netec[sponsor organization] version 01/2017 15 for...

Health Care Coalition [Insert airborne transmissible special pathogen name] Tabletop

Exercise

This Situation Manual (SitMan) is to serve as a template to support Health Care Coalitions in assessing their progress in the preparation for management of a patient with suspected or confirmed special pathogen disease, using metrics developed by HPP. This SitMan was assembled under the guidance of the NETEC Exercise Design Team and vetted through ASPR and CDC to provide exercise participants with the necessary tools for their respective roles in the exercise, but with the flexibility to adapt the exercise to the individualized needs of each coalition and varied composition of each local community.

Situation Manual[Template]

ContentsContents........................................................................................................................................................................ iii

Exercise Overview.........................................................................................................................................................5

About NETEC.................................................................................................................................................................7

Using This Document....................................................................................................................................................8

Preface............................................................................................................................................................................9

General Information....................................................................................................................................................10Background.............................................................................................................................................................10Purpose...................................................................................................................................................................10HPP Measures.........................................................................................................................................................11Scope.......................................................................................................................................................................12Target Capabilities.................................................................................................................................................12Exercise Objectives and Target Capabilities.......................................................................................................12Participant Roles and Responsibilities................................................................................................................14Exercise Structure..................................................................................................................................................15Exercise Guidelines...............................................................................................................................................15Exercise Assumptions and Artificialities.............................................................................................................16

Exercise 1: Patient Self-Presents at Frontline Hospital..........................................................................................17Scenario..................................................................................................................................................................17Module 1: Emergency Department Arrival of PUI Initial Response: Alert/Notification, Coordination, Risk Communications....................................................................................................................................................17Module 2: Ongoing Operations: Coordination, Reporting, Sharing Resources..............................................18Scenario..................................................................................................................................................................18Module 3: Transfer Decision to Regional Ebola and Other Special Pathogen Treatment Center and Transportation Logistics.......................................................................................................................................20Scenario..................................................................................................................................................................20Module 4: Returning to Normalcy: Recovery Operations..................................................................................21Scenario..................................................................................................................................................................21Conclusion..............................................................................................................................................................21

Exercise 2: Multiple Patients arrive at [insert Assessment Hospital or ETC Name] in your Health care Coalition ......................................................................................................................................................................22

Scenario..................................................................................................................................................................22Module 1: Health care Coalition Coordination and Planning Transportation for Multiple Patients with suspected [insert airborne transmissible special pathogen name] From Private Residence........................22Module 2: Multiple Patient Transport with suspected [insert airborne transmissible special pathogen name] From Private Residence.............................................................................................................................23Module 3: Health care Coalition Surge Capacity................................................................................................25Scenario..................................................................................................................................................................25

Appendix A: Exercise Schedule.................................................................................................................................26

Appendix B: Invited Exercise Participants...............................................................................................................27

Appendix C: Relevant Plans.......................................................................................................................................28

Appendix D: After Action Report/Improvement Plan (AAR/IP)...............................................................................29

Appendix E: Participant Feedback Form..................................................................................................................34

Appendix F: Acronyms and Abbreviations...............................................................................................................36

Exercise Overview

Exercise Name [Insert the formal name of exercise, which should match the name in the document header]

Exercise Date [Month/Day, Year]

ScopeThis exercise is a [exercise type], planned for [exercise duration] at [exercise location]. Exercise play is limited to [exercise parameters].

Mission Area(s) [Prevention, Protection, Mitigation, Response, and/or Recovery]

Target Capabilities

Foundation for Health Care and Medical Readiness, Health Care and Medical Response Coordination, Continuity of Health Care Service Delivery, and Medical Surge. [List any other applicable target capabilities being exercised]

Objectives

1. Examine the Health Care Coalition’s role to its members to prepare for, respond to, and recover from a special pathogen event.

2. Assess the notification and communication processes among local, state, and federal public health, EMS, and the healthcare delivery system partners, including the Regional Ebola and Other Special Pathogen Treatment Center.

3. Examine the healthcare coalition’s role to support EMS capabilities, and its role to help determine the most appropriate method for transportation (e.g., air versus ground).

If applicable, evaluate EMS ground transportation coordination with air transportation resources.

4. Assess just-in-time PPE don/doff training resources and PPE availability for EMS, and other involved healthcare delivery system personnel

5. [List any additional exercise objectives]

Hazard Special Pathogen

Scenario [Insert a brief overview of the exercise scenario, including scenario impacts (2-3 sentences)]

Sponsor(s) [Insert the name of the sponsor organization, as well as any grant programs being utilized, if applicable]

Participating Organizations

[Agency/Department]

[Agency/Department]

NETEC [Sponsor Organization]Version 01/2017 5

FOR OFFICIAL USE ONLYHomeland Security Exercise and Evaluation Program (HSEEP)

Point of Contact

[Agency/Department] NameTitleEmailPhone

[Agency/Department] NameTitleEmailPhone

About NETEC NETEC is a consortium of Emory University, NYC Health + Hospitals, and the University of Nebraska Medical Center, as equal partners, who support ASPR and the CDC by developing the National Ebola Training and Education Center. All three institutions have safely and successfully cared for patients with Ebola virus disease (EVD) since the beginning of the outbreak in March 2014. The goal of the NETEC, over its five-year funding period, is to increase the



competency of health care and public health workers and the capability of health care facilities to deliver safe, efficient, and effective Ebola patient care through the nationwide, regional network for Ebola and other infectious diseases. The objectives are: 1) to develop metrics to measure facility and health care worker readiness (including health care worker training) to care for patients infected with the Ebola virus and other special pathogens (e.g. variola or smallpox, Marburg virus, Yersinia pestis, anthrax, or measles); 2) to conduct assessments, monitoring, recognition reporting, and validation of Regional and State Ebola Treatment Centers and Assessment Hospitals; 3) to create and maintain a comprehensive suite of timely and relevant educational materials related to care of patients with Ebola and other special pathogens; 4) to identify and incorporate best practices regarding how health departments and treatment centers collaborate around the care of patients with Ebola virus infection; 5) to establish a web-based repository to support dissemination of timely and relevant materials; 6) to support the public health departments and health care facilities through training and technical assistance.

Exercise Resource Technical Assistance:NETEC offers 24/7 Exercise Technical Assistance with subject matter experts who are versed in HSEEP exercise design and development. Exercise Technical Assistance can include onsite exercise assistance (e.g., observer, evaluator), and remote technical assistance (e.g., exercise development).

Contact: [email protected]

NETEC Exercise Resource Team: Name Institution TitleElizabeth L. Beam, PhD, RN University of Nebraska Medical

Center, Nebraska Biocontainment Unit

Project Coordinator and Assistant Professor

Nicholas V. Cagliuso, Sr., PhD, MPH

NYC Health + Hospitals Assistant Vice President, Emergency Management

Shawn G. Gibbs, PhD, MBA, CIH Indiana University, School of Public Health-Bloomington

Executive Associate Dean and Professor

Syra S. Madad, DHSc, MSc, MCP NYC Health + Hospitals Director, System-wide Special Pathogens Program

Kristine Sanger, BS, MT(ASCP) University of Nebraska Medical Center, Center for Preparedness Education

Director of Hospital Training and Exercise Programs

Sam Shartar, RN, CEN Emory University Office of Critical Event Preparedness and Response CEPAR

Senior Administrator

Using This Document1. As the exercise planner, you are responsible for scheduling the exercise and inviting the appropriate

individuals to the exercise. It is best to plan for approximately 30 minutes to 2 hours per module, plus 1+ hours for instructions and hotwash (Appendix A).

2. This template should be customized to meet each end users unique requirements. Insert appropriate selection into highlighted gray areas.

3. You will need to assign someone to facilitate and evaluate the exercise at your site and write the After Action Report and Improvement Plan (Appendix D).

4. To ensure the best possible learning opportunity for your team, it is strongly recommended that you already have a plan in place for the processes that are discussed in this document. The scenarios and injects that



mailto:[email protected]

comprise this exercise are designed to stimulate thought and discussion about your current plans and how to improve them.

5. On the day of the exercise, your team should gather in a conference or training room to participate in the exercise using a single computer, combination computer/LCD projector and/or handouts.

6. Inviting members of your local Public Health, Fire and Rescue, Law Enforcement, and/or Emergency Medical Services (EMS) teams and all other applicable Health Care Coalition members.

7. Invite your entire Incident Management Team to this Tabletop exercise. If you do not have an Incident Management Team, some suggestions of people to invite would be:

Health Care Coalition Leaders Health Care Coalition Leaders Members Senior Administrative Leadership (e.g., CEO, COO, CMO, CNO or CFO) Emergency Preparedness Coordinator Physicians Nurses Nursing Assistants Facilities Management staff Environmental Services staff Infection Prevention Leadership Respiratory Protection Program/Industrial Hygiene Leadership Any other staff members that participate in patient care

8. Have all participants fill out a Sign-in Sheet.9. It is helpful for each participant to have a handout that includes the scenario and questions for the exercise

so they can follow along and reference the scenario as questions arise during the discussion. This document should be developed based on the portion of the exercise that is planned.

10. Have all participants fill out a Participant Feedback form and hand back to you. (Appendix E) 11. To ensure this Tabletop Exercise meets the requirements of Joint Commission, you will need to have

additional community members (local Public Health, etc.) in the room for your discussion. (FOR JOINT COMMISSION ACCREDITED FACILITIES ONLY)

12. An After Action Report (AAR) template (Appendix D) is included in this packet. This is a template for you to fill out after the exercise is completed. It will allow you to easily organize your strengths, weaknesses and improvement planning efforts.

PrefaceThere has been much focus and effort toward preparedness for Ebola. Ebola is transmitted through direct contact with infected blood or body fluids. Health care facilities and coalitions in the United States must also be prepared for diseases that are transmitted through the air such as Middle East Respiratory Syndrome Coronavirus (MERS-CoV), or other highly communicable airborne and non-airborne diseases. By building upon the established regional, tiered approach set forth by Health and Human Services (HHS) for Ebola Virus Disease (EVD), health care facilities can support a system of care for special pathogens including highly communicable airborne and non-airborne diseases, all of which pose a significant burden on the healthcare delivery system and require real time access to expertise in infectious disease management; and involve strategies and tactics related to overall preparedness to special pathogens.



Table 1: Airborne Transmissible Disease Selection

Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV)

Severe Acute Respiratory Syndrome (SARS)

Highly Pathogenic Avian Influenza (HPAI)

*This is not an exhaustive list. Other airborne diseases may be substituted.

Health care facilities and coalitions should outline plans from an ‘all hazards’ view for administrative, environmental, and communication measures that will be required to prevent spread, and manage the impact on patients, the facility, and staff for incidences involving special pathogen diseases.

By exercising plausible scenarios of varying type and magnitude, including highly communicable airborne and non-airborne diseases, health care facilities and coalitions can maintain an appropriate level of readiness to respond effectively to special pathogen diseases. The proposed airborne diseases in Table 1 are not an exhaustive list of highly communicable airborne diseases. Rather, the list is an impetus to serve as a starting point for health care facilities and coalitions to begin planning for other highly communicable diseases.

NOTE: The purpose of this template is to give end-users an option when designing, conducting, and evaluating special pathogen exercises and to choose a single airborne-transmissible pathogen and expeditiously proceed.

This exercise template has been developed by the National Ebola Training and Education Center (NETEC) utilizing the Homeland Security Exercise and Evaluation Program (HSEEP), which provided a “set of guiding principles for exercise programs, as well as a common approach to exercise program management, design and development, conduct, evaluation, and improvement planning.” (http://www.fema.gov/media-library-data/20130726-1914-25045-8890/hseep_apr13_.pdf).

This is a facilitated discussion intended to probe and explore the healthcare system’s ability to identify and stabilize a patient potentially infected with an airborne transmitted highly infectious disease; to initiate care and implement special protocols that may be required for the protection of the healthcare facility staff; and to coordinate such care with other Health Care Coalition (HCC) partners, including emergency medical services (EMS), public health and emergency management.

The series of questions included in this document are intended to initiate discussion and descriptions of how the HCC would respond to such an event. It is not anticipated that every question will be answered in every session, or that every question is relevant to every HCC setting. Please utilize these questions to explore the many complexities involved in the management of an airborne transmitted highly infectious disease patient(s), whether it is conducted in one session, or divided up over a number of sessions in which specific topics (i.e. coordination of EMS transport, implementation of patient care protocols, development of joint messaging, etc.) are discussed in greater detail.

Please note that there are five (5) specific measures (framed as specific questions in the body of this document) that are REQUIRED to be asked and answered by coalitions that received funding through the HPP Ebola Preparedness and Response Activities funding opportunity announcement. Four (4) other HPP measures are also included to probe Health Care Coalition's ability to prepare for and respond to a special pathogen case(s) within their coalition.



http://www.fema.gov/media-library-data/20130726-1914-25045-8890/hseep_apr13_.pdf

http://www.fema.gov/media-library-data/20130726-1914-25045-8890/hseep_apr13_.pdf

General InformationBackgroundThe Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities funding opportunity announcement (FOA) provided awardees with the funds to support a regional, tiered approach for the management of Ebola and other special pathogens. At the state or jurisdictional level, awardees are supporting health care facilities that are capable of serving as State-Designated Ebola Treatment Centers (ETC) and Assessment Hospitals for their state(s) or jurisdictions, as well as supporting health care coalitions to prepare Frontline Facilities, emergency medical services (EMS) and the overall healthcare system in Ebola preparedness activities. The development of a regional Ebola/Special Pathogens treatment strategy, and Ebola/Special Pathogen healthcare system preparedness and response, are being supported by ASPR through HPP. HPP has created specific metrics to assess progress in meeting the goals of the HPP Ebola Preparedness and Response Activities FOA.

PurposeThe purpose of this exercise is to evaluate, review, and measure the regional response elements related to the health care coalition, in which the health care coalition must: 1) Ensure that the EMS system is capable of safely transporting patients with a highly infectious, airborne disease, 2) Enhance the competency of health care workers, including EMS personnel in the coalition, and clinical laboratories, and, by supporting annual training and exercises, 3) Rapidly communicate the presence of a PUI across the health care coalition, including health departments, and 3) Assess and report on PPE supplies from/for their members. The results of this exercise may be used to support fulfill the coalition-related HPP measures.

HPP MeasuresConduct of the facilitated discussion should allow sufficient flexibility for exercise participants to initiate the collection of required information in the context of the exercise. It is anticipated that the results of these measures will be reported to the exercise leader in the allotted timeframe, but likely after the conclusion of the “discussion” portion of the exercise.

REQUIRED HPP Measures (Assessment Hospital or Health Care Coalition):Required HPP Measures*

9 A.B. Time, in minutes, it takes an assessment hospital to identify and isolate a patient with Ebola or other highly infectious disease (e.g., MERS-CoV, measles, etc.) following emergency department triage, as evidenced by a real-world case or no-notice exercise (Goal: Within 5 minutes).

OTHER HPP Measures (Coalition):Required HPP Measures*

15 A.C. Proportion of Frontline facilities that receive information from their coalition on the quantity and location of personal protective equipment (PPE) supply within 8 hours of a patient under investigation’s arrival at a coalition member facility (Goal: = 100%).

16 A.C. Proportion of Frontline facilities that have received coalition-funded training (Goal: 75%).17 A.C. Proportion of EMS agencies that are required to execute the awardee’s CONOPs that are in engaged in

all phases of the Ebola and other special pathogen preparedness process (Goal: 100%). Note: this is a coalition and awardee measure.

18 A.C. Proportion of coalitions within an awardee’s jurisdiction that participate in the Health care-Associated NETEC [Sponsor Organization]Version 01/2017 10


Infection (HAI)/Infection Control advisory group (Goal: 80%).

OTHER HPP Measures (supporting regional network measures that may be tested during this exercise that may support a coalition’s preparedness and response):

OTHER HPP Measures+ 10 A.B. Proportion of health care and emergency medical services (EMS) workers in PPE that an AM/DAM

suspected Ebola patient under investigation (PUI) makes contact with after health department notification to the assessment hospital or ETC (Assessment Hospital HPP Measure, Goal: 100%).

11 A.B. Number of health care and EMS workers in PPE that an AM/DAM suspected Ebola patient makes contact with after health department notification until isolation (Assessment Hospital HPP Measure, Goal: =<3).

21 B.A. Proportion of states/jurisdictions in the HHS region for which a current written and signed agreement is in place to transfer patients from assessment hospitals or ETCs to the regional Ebola and other special pathogen treatment center (Goal: 100%)

22 B.A. Proportion of states/jurisdictions in the HHS region that have demonstrated the ability to move a patient across jurisdictions by ground or air to a regional Ebola and other special pathogen treatment center, as evidenced by a real-world event or participation in a multi-jurisdiction exercise (Goal: 100%).

Hospital Preparedness Program (HPP) Measure Manual: Implementation Guidance for Ebola Preparedness Measures. July 2015 Version 7.0 *[This document has been modified and approved by ASPR to include Measures for special pathogens] +[These measures have been pulled from select regional network HPP measures that can be used as a guide for HCC's to increase preparedness and planning]http://netec.org/wp-content/uploads/2015/10/2015-HPP-Measure-Manual-Implementation-Guidance-for-Ebola-Preparedness-NETEC-Exercise-Template-Add-On.pdf

ScopeHealth Care coalition: The exercise will focus on emergency operations, coordination and information sharing aspects of the response to a PUI or a patient with confirmed [insert airborne transmissible special pathogen name]. Furthermore, it will explore the coordination and interplay between the multiple agencies and emergency response disciplines that comprise the HCC.

Target CapabilitiesThe Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities (CFDA #93.817) Funding Opportunity Announcement (FOA) and the NETEC are utilizing a capabilities-based planning approach as directed by National Preparedness Priorities. Capabilities-based planning focuses on planning under uncertainty, since the next emergence of a highly infectious disease in the United States can never be forecast with complete accuracy. Therefore, capabilities-based planning takes an approach to planning and preparation which builds capabilities that can be applied to a wide variety of special pathogens.

The NETEC Exercise Design Team, ASPR and CDC have determined the capabilities listed below from the priority capabilities identified in the 2017 – 2022 Health Care Preparedness and Response Capabilities and exercise requirements. These capabilities provide the foundation for development of exercise objectives and scenario, as the purpose of this exercise is to measure and validate performance of these capabilities and their associated critical tasks: Foundation for Health Care and Medical Readiness, Health Care and Medical Response Coordination, Continuity of Health Care Service Delivery, and Medical Surge.



http://netec.org/wp-content/uploads/2015/10/2015-HPP-Measure-Manual-Implementation-Guidance-for-Ebola-Preparedness-NETEC-Exercise-Template-Add-On.pdf

http://netec.org/wp-content/uploads/2015/10/2015-HPP-Measure-Manual-Implementation-Guidance-for-Ebola-Preparedness-NETEC-Exercise-Template-Add-On.pdf

Exercise Objectives and Target CapabilitiesThe following objectives assess HCC's emergency management procedures, information and resource sharing procedures, coordination of transportation processes, identify areas for improvement, and achieve communication, coordination and collaboration with internal and external stakeholders.

Table 1: Exercise Objectives and Associated Target Capabilities

Objective Related Target Capabilities1. Examine the Health Care Coalition’s role to its members to

prepare for, respond to, and recover from a special pathogen event.

Foundation for Health Care and Medical ReadinessHealth Care and Medical Response CoordinationContinuity of Health Care Service Delivery



3. Examine the health care coalition’s role to support EMS capabilities, and its role to help determine the most appropriate method for transportation (e.g., air versus ground).

a. If applicable, evaluate EMS ground transportation coordination with air transportation resources.




5. [Other] [Other]

Table 2: Target Capabilities Defined1

Target Capability DefinitionFoundation for Health Care and Medical Readiness

The community has a sustainable health care coalition (HCC) comprised of members with strong relationships that can identify hazards and risks and prioritize and address gaps through planning, training, exercising, and managing resources.

Health Care and Medical Response Coordination

Health care organizations, the HCC, their jurisdiction(s), and the ESF-8 lead agency plan and collaborate to share and analyze information, manage and share resources, and coordinate strategies to deliver medical care to all populations during emergencies and planned events.

1 https://www.phe.gov/Preparedness/planning/hpp/reports/Documents/2017-2022-healthcare-pr-capablities.pdf



Target Capability DefinitionContinuity of Health Care Service Delivery

Health care organizations, with support from the HCC and the ESF-8 lead agency, provide uninterrupted, optimal medical care to all populations in the face of damaged or disabled health care infrastructure. Health care workers are well-trained, well-educated, and well-equipped to care for patients during emergencies. Simultaneous response and recovery operations result in a return to normal or, ideally, improved operations.

Medical Surge Health care organizations including hospitals, EMS, and out of hospital providers deliver timely and efficient care to their patients even when the demand for health care services exceeds available supply. The HCC, in collaboration with the ESF-8 lead agency, coordinates information and available resources for its members to maintain conventional surge response. When an emergency overwhelms the HCC’s collective resources, the HCC supports the health care delivery system’s transition to contingency and crisis surge response and promotes a timely return to conventional standards of care as soon as possible.

Participant Roles and Responsibilities Players. Players are personnel who have an active role in discussing or performing their regular roles and

responsibilities during the exercise. Players discuss or initiate actions in response to the simulated emergency.

Observers. Observers do not directly participate in the exercise. However, they may support the development of player responses to the situation during the discussion by asking relevant questions or providing subject matter expertise.

Facilitators. Facilitators provide situation updates and moderate discussions. They also provide additional information or resolve questions as required. Key Exercise Planning Team members also may assist with facilitation as subject matter experts (SMEs) during the exercise.

Evaluators. Evaluators are assigned to observe and document certain objectives during the exercise. Their primary role is to document player discussions, including how and if those discussions conform to plans, polices, and procedures.

Exercise StructureThis will be a facilitated tabletop exercise. Modules should be edited and adapted to meet the needs and objectives of the local HCC; the provided modules are only a starting point for your HCC and facility/organization. The objectives should be designed to measure local concepts of operation specific to these missions. The series of facilitated discussion questions that follow may be asked in a joint session, with all HCC stakeholders present, or broken up by discipline over multiple days with a focus on specific members of the HCC. The following key items will be covered in the corresponding modules:

1. Exercise 1: Patient Arrives at Frontline Hospital via EMS a. Module 1: Emergency Department Arrival of [insert airborne transmissible special pathogen

name] PUI Initial Response: Alert/Notification, Coordination, Risk Communicationsb. Module 2: Ongoing Operations: Coordination, Reporting, Sharing Resourcesc. Module 3: Transfer Decision to Regional Ebola and Other Special Pathogen Treatment Center and

Transportation Logisticsd. Module 4: Returning to Normalcy: Recovery Operations



2. Exercise 2: Multiple Patients Arrive at [insert Assessment Hospital or ETC name] in your Healthcare Coalition

a. Module 1: Health Care Coalition Coordination and Planning Transportation for Multiple Patients with suspected [insert airborne transmissible special pathogen name] From Private Residence

b. Module 2: Multiple Patient Transport with suspected [insert airborne transmissible special pathogen name] From Private Residence

c. Module 3: Health Care Coalition Surge Capacity

Each module will include an update that summarizes the key events occurring within that time frame. Following the updates, participants can review the situation and engage in small or large group discussions of appropriate response issues. The modules provided represent a framework for the development of a HCC exercise. A module should be selected for discussion and adapted based upon the needs and objectives of each unique HCC.

Exercise Guidelines This is an open, low-stress, no-fault environment. Varying viewpoints, even disagreements, are expected. Respond based on your knowledge of current plans and capabilities (i.e., you may use only existing assets)

and insights derived from training. Decisions are not precedent setting and may not reflect your organization’s final position on a given issue.

This is an opportunity to discuss and present multiple options and possible solutions. Issue identification is not as valuable as suggestions and recommended actions that could improve

response and preparedness efforts. Problem-solving efforts should be the focus. This exercise is intended to raise more questions than answers. It is a tool to be used to help assess and

improve your current planning. Given all of the variables involved in this type of scenario, many questions and potential issues have been

omitted in the interests of available time and exercise objectives.

Exercise Assumptions and ArtificialitiesIn any exercise, a number of assumptions and artificialities may be necessary to complete play in the time allotted. During this exercise, the following apply:

The scenario is plausible, and events occur as they are presented. There is no “hidden agenda”, nor any trick questions. All players receive information at the same time. Information is provided for situational awareness. Participants should realize that in a real event, this

information might not be available to them with such immediacy for decision-making. This is an artificiality to allow for a comprehensive discussion.



Exercise 1: Patient Arrives at Frontline Hospital via EMS

Scenario

Day One, 8:00 am

A 39-year-old febrile male with 2-day history of severe acute respiratory symptoms including persistent cough, difficulty breathing and myalgia was transported via EMS to a Frontline Hospital (non-assessment or treatment center) in your Health Care Coalition (HCC). The patient’s wife rode in the ambulance to the hospital with him. Medical history obtained from the wife revealed recent travel history to [insert relevant country] with his wife and two children. Three hours into the emergency room visit the patient goes into cardiac arrest and is put on a ventilator. No laboratory confirmation on pathogen has been made yet.

HPP Required Measures: 9 A.B. Time, in minutes, it takes an assessment hospital to identify and isolate a patient potentially infected

with Ebola or other highly infectious disease (e.g., MERS-CoV, measles, etc.) following emergency department triage, as evidenced by a real-world case or no-notice exercise (Goal: Within 5 minutes).

15 A.C. Proportion of Frontline facilities that receive information from their coalition on the quantity and location of personal protective equipment (PPE) supply within 8 hours of a patient under investigation’s arrival at a coalition member facility (Goal: = 100%)

16 A.C. Proportion of Frontline Facilities that have received coalition-funded training (Goal: 75%).

Module 1: Emergency Department Arrival of PUI: Initial Response Alert/Notification, Coordination, Risk Communications

Key Issues Identification Isolation Notification Risk Communication

QuestionsThe following questions are provided as suggested subjects that we may address as the discussion progresses. These questions are not meant to constitute a definitive list of concerns to be addressed, nor is there a requirement to address every question.

1. What is the time, in minutes, it takes the Frontline Hospital to identify and isolate a patient under investigation for an airborne transmissible special pathogen following triage, as evidenced by a real world case or no-notice exercise (Note: Assessment Hospital HPP Measure 9 A.B., Goal: Within 5 minutes)

Please note: While the Assessment Hospital will likely be the data source for this measure, it is important to share this information with the coalition so that member facilities have adequate situational awareness and can begin to anticipate their own individual preparedness efforts and prepare to support the greater needs of the region’s healthcare system.

15 [Sponsor Organization]FOR OFFICIAL USE ONLY

Homeland Security Exercise and Evaluation Program (HSEEP)

2. What is the hospital’s responsibility to your coalition at this point? 3. What are the first three things you are going to do at your coalition once the high risk patient is identified and

you are notified? Who are you responsible for notifying? 4. Do you have a plan for communicating to your internal staff, and the appropriate public health and

healthcare partners to let them know what is happening? Are these communications the responsibility of the HCC, the healthcare organization, or both? How are these communications coordinated?

5. How are organizations, agencies and facilities that comprise the HCC communicating and coordinating their situation with other HCC members (e.g. clinics, other hospitals, health departments, emergency management, EMS, etc.) and interested parties outside the coalition? Is this an automated/electronic system? Has this system been tested?

6. What messages are important to get to both other members of the coalition and the general public? 7. Identify three actions you are asking your response partners to take to help you within the first 24 hours of

the response, including emergency management, public health, law enforcement, fire/EMS and other HCC members.

8. How does a Frontline Facility with a PUI receive the most up-to-date information on the quantity, types, and location of personal protective equipment (PPE) supply?

9. What is the proportion of Frontline Facilities that receive information from their coalition on the quantity and location of personal protective equipment (PPE) supply within 8 hours of a patient under investigation’s (PUI) arrival at a coalition member facility? (HPP Measure 15 A.C., Goal: 100%)

10. What monitoring practices will the facility have for those exposed (e.g. staff, patient family, etc.) to the PUI? What role does the coalition have in these monitoring processes?

11. Is the Assessment Hospital or other facility performing laboratory testing of the PUI? How long will it take to determine if the PUI is confirmed to have [insert airborne transmissible special pathogen name]?

12. What proportion of Frontline Facilities have received coalition-funded training? (HPP Measure 16 A.C., Goal: 75%).

Module 2: Ongoing Operations Coordination, Reporting, Sharing Resources

Scenario

Day Two, 8am

The patient is highly suspected for [insert airborne transmissible special pathogen name] but laboratory-confirmation has not been received yet. The patient’s condition is deteriorating. Arrangements for ongoing treatment at the Regional Ebola and Other Special Pathogen Treatment Center are being discussed. The patient's wife and two children are being actively monitored by the Department of Health.

Key Issues Coordination Reporting Sharing Resources

Questions1. What resources might your organization need and what resources can you anticipate obtaining from other

HCC members within the next 72 hours of the response? 2. What are the response priorities within your organization for this patient care event?



3. How is the decision to treat in place or transfer made? Who is involved? Does the HCC have any responsibility in this decision? How is the communication initiated?

4. How do you expect to receive information about this situation to ensure accurate information is being relayed to your staff and the public?

5. What role could your organization play in: a. Patient careb. Transportc. Care of the deceased patient (if expected) d. Securitye. Public health responsef. Media managementg. Waste management

6. What is the proportion of states/jurisdictions in your HHS region for which a current written and signed agreement is in place to transfer patients from Assessment Hospitals or ETCs to the Regional Ebola and Other Special Pathogen Treatment Center (Regional Network HPP Measure 21 B.A., Goal: 100%)

7. What is the proportion of states/jurisdictions in your HHS region that have demonstrated the ability to move a patient across jurisdictions by ground or air to a Regional Ebola and Other Special Pathogen Treatment Center, as evidenced by a real-world event or participation in a multi-jurisdiction exercise (Regional Network HPP Measure 22 B.A., Goal: 100%).

8. What HCC future training needs were identified throughout this exercise?

Module 3: Transfer Decision to Regional Ebola and Other Special Pathogen Treatment Center and Transportation Logistics

Scenario

Day Two, 11am

The patient’s diagnosis of [insert airborne transmissible special pathogen name] has been laboratory-confirmed at the Frontline Hospital within your Health Care Coalition. The decision has been made to [insert ground or air] transfer the patient to a Regional Ebola and Other Special Pathogen Treatment Center due to increased patient acuity and symptoms. The ambulance has arrived and is ready to transport.

HPP Required Measures: 17 A.C. Proportion of EMS agencies that are required to execute the awardee’s CONOPs that are in

engaged in all phases of the Ebola and other special pathogen preparedness process (Goal: 100%). 18 A.C. Proportion of coalitions within an awardee’s jurisdiction that participate in the Health care-

Associated Infection (HAI)/Infection Control advisory group (Goal: 80%).

Key Issues Coordination Transportation Logistics Information Sharing



Questions1. What is the role of the respective response partners involved in transferring the confirmed patient with

[insert airborne transmissible special pathogen name]? How are these roles coordinated?2. What communication protocols are enacted among the Frontline Hospital, Assessment Hospital, Treatment

Center, EMS agency, and public health authorities to facilitate the transfer of a [insert airborne transmissible special pathogen name] patient?

3. What is the proportion of EMS agencies that are required to execute the awardee’s CONOPS that are engaged in all phases of the Ebola and other special pathogen preparedness process? (HPP Measure 17 A.C., Goal: 100%)

4. What is the proportion of coalitions within your jurisdiction that participate in the Health Care-Associated Infection (HAI)/Infection Control advisory group (HPP Measure 18 A.C., Goal: 80%).

5. Are there mechanisms to decrease the time it takes for a transport unit to arrive at the frontline hospital?6. What additional organizations or agencies need to be notified of the pending transport?7. Who is involved in providing information and making decisions regarding the transportation of this patient,

by [insert ground or air], to the Ebola and Other Special Pathogen Treatment Center?8. What additional resources can the HCC provide in order to assure the safe and timely transport of a PUI/

confirmed [insert airborne transmissible special pathogen name] patient?

Module 4: Returning to Normalcy: Recovery Operations

Scenario

Day Three, 8am

The patient has been safely transferred to the Regional Ebola and Other Special Pathogen Treatment Center (or other State-Designated ETC) for definitive care. Coalition members are now attempting to return to normal operations, and hospitals and transport agencies are concerned about being able to get reimbursement for any additional costs incurred in the management of a confirmed [insert airborne transmissible special pathogen name] patient.

Key Issues Recovery Operations

Questions1. What steps need to be taken for the HCC and its members to return to normal operations? How is this

accomplished?2. What decontamination procedures need to be put in place for the hospital patient care areas and transport

units? What is the role of the HCC in coordinating and assuring such protocols are being implemented?3. Are there remaining waste management issues?4. What event documentation and other data collection can the HCC facilitate and coordinate in order to help

individual health care facilities and transport agencies, which responded to a [insert airborne transmissible special pathogen name] patient, assure potential for reimbursement at the conclusion of the event?



ConclusionThis concludes the evaluation of a HCC’s role in the management of a suspected and confirmed [insert airborne transmissible special pathogen name] patient. A patient may self-present to a hospital or other healthcare setting, or a patient may be initially screened and managed by an EMS transport agency. These modules are intended to assess initial identification, regional notification, coordination, resource sharing community patient surge/outbreak, and recovery from what by its very nature will be a disruptive event. The coordination of these complex steps, and reporting on the required measures, will help HCCs in their assessment of ongoing capabilities to manage such patients.

Exercise 2: Multiple Patients arrive at [insert Assessment Hospital or ETC Name] in your Health Care Coalition

ScenarioA laboratory-confirmed [insert airborne transmissible special pathogen name] patient was transported via EMS to [insert hospital name]. The patient's wife and two children who were under active monitoring for [insert airborne transmissible special pathogen name] by the Department of Health have started to display mild respiratory symptoms. The mother refuses to be separated from her children. As a result one [insert receiving facility name] in your Health Care Coalition will receive all three PUIs.



Module 1: Health Care Coalition Coordination and Planning Transportation for Multiple Patients with suspected [insert airborne transmissible special pathogen name] From Private Residence

HPP Measures: 17 A.C. Proportion of EMS agencies that are required to execute the awardee’s CONOPs that are in

engaged in all phases of the Ebola and other special pathogen preparedness process (Goal: 100%).

Key Issues Multiple patient transport from private residence Pediatric patient transport from private residence

QuestionsThe following questions are provided as suggested subjects that we may address as the discussion progresses. These questions are not meant to constitute a definitive list of concerns to be addressed, nor is there a requirement to address every question.

1. Who is involved in providing information and making decisions regarding the transportation of multiple patients in your HCC to the receiving facility?

2. What is the role of the respective response partners involved in transferring of multiple [insert airborne transmissible special pathogen name] PUIs?

3. What communication protocols are enacted among the Assessment Hospital, Treatment Center, EMS agency, and public health authorities to facilitate the transfer of multiple [insert airborne transmissible special pathogen name] PUIs?

4. What is the proportion of EMS agencies that are required to execute the awardee’s CONOPS that are engaged in all phases of the Ebola and other special pathogen preparedness process? (Coalition HPP Measure 17 A.C., Goal: 100%)

5. Are there mechanisms to decrease the time it takes for one or multiple transport units to arrive at the private residence?

6. What additional agencies need to be notified of the pending transport?7. What additional resources can the HCC provide in order to assure the safe and timely transport of multiple

[insert airborne transmissible special pathogen name] PUIs?8. What transportation services are available in your health care coalition to move these potentially highly

infectious patients to a receiving facility? a. What are special considerations for transporting multiple patients?b. What special considerations would need to be in place for a pediatric patient transport?c. How are the transportation service providers selected?d. Will multiple ambulances be needed to transport 3 patients? e. What protocols are used to guide the providers performing this service? f. Who confirms they are compliant with the preparation and implementation of the transport

protocols?9. Does the HCC or community have a media plan in place to address the concerns of the public? Who will

deal with the questions from the community members who may have made contact with the wife and two children?

10. Is there a HCC plan coordinated with other stakeholders to address national media wanting to cover the story of the outbreak or potential for an outbreak?



Module 2: Multiple Patient Transport with suspected [insert airborne transmissible special pathogen name] From Private Residence

ScenarioThe wife and two children who are under active monitoring for [insert airborne transmissible special pathogen name] by the Department of Health are located at their private home residence and require transport to [insert receiving facility name] in your Health Care Coalition.

HPP Measures: 10 A.B. Proportion of health and emergency medical services (EMS) workers in PPE that an AM/DAM

suspected Ebola patient under investigation (PUI) makes contact with after health department notification to the assessment hospital or ETC (Assessment Hospital HPP Measure, Goal: 100%).

11 A.B. Number of health care and EMS workers in PPE that an AM/DAM suspected Ebola/Special Pathogens patient makes contact with after health department notification until isolation (Assessment Hospital HPP Measure, Goal: =<3).

Key Issues Multiple patient transport from private residence Pediatric patient transport from private residence

Questions1. What preparation and equipment is needed for the EMS or transportation team for multiple patients?

a. Number of ambulances and crew required to transport multiple PUIs. Consider:i. The effect of multiple ambulances being out of service due to high risk patient transport in

your HCCb. PPE, patient isolation unit, barrier material for lining internal surfaces of the ambulance, vehicle

ventilation system (e.g., non-recirculating mode, HEPA filtration, if available)c. Engineering controls to limit airborne dissemination of the virus d. Is a portable isolation unit (PIU) appropriate for a patient with a serious airborne disease? Is a PUI

appropriate for a pediatric patient? 2. Proportion of health care and emergency medical services (EMS) workers in PPE that an AM/DAM

suspected Ebola/Special Pathogens patient under investigation (PUI) makes contact with after health department notification to the Assessment Hospital or ETC (Assessment Hospital HPP Measure 10 A.B., Goal: 100%).

3. Describe the process for transporting the patients from their private residence to the ambulance. Consider:a. Media managementb. Public health notification

4. Do you expect the standard of care to change regarding the management of these patients? If so, have you engaged in crisis standards of care planning?

5. What is your communication plan with the receiving facility, public health and other authorities?6. Implement your activation checklist of particular steps that must be done to prepare the clinical environment

for safe receipt of the patients. Consider:a. What is the process for moving the patients from the transport vehicle to the patient reception area

(security, signage, etc.)?b. What equipment needs to be gathered and pre-positioned? c. What personal protective equipment needs to prepared and gathered? d. What staff and ancillary support need to be notified? e. Have enough waste containers and safe storage spaces been prepared?



f. What special considerations do you have in place for a pediatric patient transport?7. Establish your personal protective equipment plans for transport and patient care during transport based

upon the transmission and exposure risks of the disease. Considerations:

Patient isolation methods Patient PPE (i.e., non-intubated patients to don on surgical mask until in an airborne

infection isolation room (AIIR) or have patient cover the mouth/nose with tissue when coughing

Other source control measures (i.e., confining the spread of respiratory secretions at the patient level) Pain treatment Aerosol-generating procedures if deemed medically necessary (e.g., aerosol medication

administration, airway suctioning, intubation) Type of clinical provider to accompany Body fluid, secretions (including respiratory secretions) containment Monitoring devices Combative patient Pediatric patient Donning location for EMS Doffing location for EMS Patient expiration Length of transport and patient care handoff Crisis standards of care Intervention or non-intervention in case of sudden clinical deterioration (e.g., respiratory or

cardiac arrest)?8. Number of health care and EMS workers in PPE that an AM/DAM suspected Ebola patient makes contact

with after health department notification until isolation (Assessment Hospital HPP Measure 11 A.B., Goal: =<3).

Module 3: Health Care Coalition Surge Capacity

ScenarioAll three family members including wife and two children have laboratory-confirmed [insert airborne transmissible special pathogen name]. The wife's place of employment and the children's nursery school have been notified of the confirmed diagnosis and have been instructed to monitor all close contacts for symptoms. Since it is currently flu season, the challenge of differentiating symptoms of seasonal influenza and [insert airborne transmissible special pathogen name] has arisen.

HPP Measures: 15 A.C. Proportion of frontline facilities that receive information from their coalition on the quantity and

location of personal protective equipment (PPE) supply within 8 hours of a patient under investigation’s (PUI) arrival at a coalition member facility (Goal: 100%).

16 A.C. Proportion of frontline facilities that have received coalition-funded training (Goal: 75%).

Key Issues Surge capacity Available resources



Questions1. What are the critical elements the HCC can assist its coalition member facilities with during this surge

event? Consider:a. Credentialing of healthcare volunteers b. Educating health care workers to support community's healthcare needs (i.e., behavioral support)c. Plans to manage fatalities d. Plans or agreements to divert an influx of patients at coalition member facilitiese. Identifying hospital bed surge capacity f. Procurement of emergency resources (i.e., PPE) g. Decontamination services

2. What mechanism do you have in place for multiple coalition member facilities within your coalition to receive information on the quantity and location of personal protective equipment (PPE) supply for PUIs during a surge event? (Coalition HPP Measure 15 A.C., Goal <8 hours/100%)

3. Coalition member facilities are asking for immediate funding for training to increase workforce. Is your HCC able to provide additional coalition funded training to accommodate the surge event? (Coalition HPP Measure 16 A.C., Goal: 75%)

4. Communication strategies or plans that are interoperable with other response partners for situational awareness.

5. Do you have pre-determined designated locations to evaluate the influx of "worried well" patients? Do these locations have pre-determined staff to work in these locations? Have they been trained?

Appendix A: Exercise ScheduleSuggested Time ActivityVaries Facilitator/Evaluator Briefing and Registration20 – 30 minutes Welcome and Introductory Briefing

Participant Introductions (Players, Facilitator(s), Evaluators, Observers) Exercise Overview

Agenda Guidelines Assumptions and Artificialities Evaluation

120 minutes Exercise 1: Patient Self-Presents to Frontline Facility Module 1 Module 2 Module 3 Module 4

60 minutes Exercise 2: Multiple Patients Arrive at [insert Assessment Hospital or ETC name] in your Health Care Coalition



Suggested Time Activity Module 1 Module 2 Module 3

30 minutes Hot Wash/Closing Remarks/Participant Feedback FormsVaries Facilitator/Evaluator Debrief



Appendix B: Invited Exercise ParticipantsMembers of the following agencies were invited to participate in this exercise:

Invited OrganizationsLocal (City/County)[Agency/Department 1][Agency/Department 2]State[Agency/Department 1][Agency/Department 2]Federal[Agency/Department 1][Agency/Department 2]Other

25FOR OFFICIAL USE ONLY


Appendix C: Relevant Plans The plans listed below are associated with the response actions described in this exercise:

Facility [Document name]

[Document name]

Other [State/Federal] [Document name]

[Document name]

26FOR OFFICIAL USE ONLY


Situation Manual(SitMan)

Appendix D: After Action Report/Improvement Plan (AAR/IP)Exercise Overview

Exercise Name 2016-2017 Health Care Coalition Tabletop Exercise

Exercise Dates Month XX, XXXX

ScopeHealth Care Coalition: The exercise will focus on how HCC's respond to a patient(s) with suspected and confirmed airborne transmitted special pathogens.

Mission Area(s)

Target Capabilities Foundation for Health Care and Medical Readiness Health Care and Medical Response Coordination Continuity of Health Care Service Delivery Medical Surge

Objectives

1. Examine the Health Care Coalition’s role to its members to prepare for, respond to, and recover from a special pathogen event.


3. Examine the healthcare coalition’s role to support EMS capabilities, and its role to help determine the most appropriate method for transportation (e.g., air versus ground).

If applicable, evaluate EMS ground transportation coordination with air transportation resources.


5. [List any additional exercise objectives

Threat or Hazard Airborne transmitted special pathogen

Scenario Highly Infectious Disease Management

Sponsor Special pathogen health care system preparedness, response, and the development of a regional special pathogen treatment strategy were supported by ASPR through HPP.

Participating Organizations

Point of Contact

Analysis and Improvement Recommendations

27[Sponsor Organization]

Situation Manual(SitMan)

Issue 1: Record your top areas of improvement here. Be sure to elaborate on your findings (what happened) specific to your organization and what you think should be done to improve your processes.

Issue 2:

Issue 3:

Issue 4:

Issue 5:

Issue 6:

28[Sponsor Organization]

Analysis of Target Capabilities

Aligning exercise objectives and target 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 target capabilities, and performance ratings for each target capability as observed during the exercise and determined by the evaluation team.

Objective Target CapabilityPerformed

without Challenges

(P)

Performed with Some Challenges

(S)

Performed with Major Challenges

(M)

Unable to be Performed (U)

[Objective 1] [Target capability]



[Objective 4] [Target capability]Ratings Definitions: Performed without Challenges (P): The targets and critical tasks associated with the core 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 core 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 core 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 core capability were not performed in a manner that achieved the objective(s).

Table 1. Summary of Target Capability PerformanceThe following sections provide an overview of the performance related to each exercise objective and associated target capability, highlighting strengths and areas for improvement.

[Objective 1]The strengths and areas for improvement for each target capability aligned to this objective are described in this section.

[List Applicable Target Capabilities]

Strengths:The [full or partial] capability level can be attributed to the following strengths:

Strength 1: [Observation statement]


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

31

Area for Improvement 1: [Observation statement. This should clearly state the problem or gap; it should not

include a recommendation or corrective action, as those will be documented in the Improvement Plan.]

Reference: [List any relevant plans, policies, procedures, regulations, or laws.]

Analysis: [Provide a root cause analysis or summary of why the full capability level was not achieved.]

Area for Improvement 2: [Observation statement]



[Objective 2]The strengths and areas for improvement for each target capability aligned to this objective are described in this section.

[List Applicable Target Capabilities 2]

Strengths:The [full or partial] capability level can be attributed to the following strengths:Strength 1: [Observation statement]


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

Area for Improvement 1: [Observation statement. This should clearly state the problem or gap; it should not

include a recommendation or corrective action, as those will be documented in the Improvement Plan.]



Area for Improvement 2: [Observation statement]



32

Improvement Plan

This IP has been developed specifically for [Organization or Jurisdiction] as a result of [Exercise Name] conducted on [date of exercise].

Target Capability Issue/Area for Improvement Corrective Action Capability

Element2Primary Responsible Organization

Organization POC Start Date Completion

DateTarget Capability 1:[Capability Name]

1. [Area for Improvement]

[Corrective Action 1]






Target Capability 2:[Capability Name]








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

33

Appendix E: Participant Feedback Form

Name (optional):_______________________________________

Facilities represented: ______________________________________

Participant Recommendations and Corrective Actions1. Based on your facility actions and your opinions (not the results of the hotwash), list the top three strengths

you identified.

2. Based on your facility actions and your opinions (not the results of the hotwash), list the top areas you identified that are in need of improvement.

The information you provide in this document will be used to inform the After Action Report and After Action Conference.

34

Overall program rating:

Excellent Above average Average Fair Poor

Please provide any recommendations on how this exercise or future exercises could be improved and/or enhanced.

35

Appendix F: Acronyms and AbbreviationsThe following acronyms and abbreviations appear in this document and/or are likely to be heard during exercise discussion.

Acronym Term

AAR After Action ReportAAR/IP After Action Report/Improvement PlanAIIR Airborne Infection Isolation RoomAM Active monitoring ASPR Office of the Assistant Secretary for Preparedness and ResponseCDC Centers for Disease Control and PreventionDAM Direct active monitoring ED Emergency DepartmentEMS Emergency Medical ServicesETC Ebola treatment centers EVD Ebola virus disease HCC Health Care Coalition HPP Hospital Preparedness Program HSEEP Homeland Security Exercise and Evaluation ProgramNETEC National Ebola Training and Education CenterPIU Portable isolation unit POC Point of ContactPPE Personal Protective EquipmentPUI Person Under InvestigationSitMan Situation ManualSME Subject matter expertTTX Tabletop exercise

36