2013 Phase III: Tabletop Exercise

The 2013 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 • California Emergency Management • Response partners representing local health departments, emergency medical services, public safety and healthcare facilities

Welcome and Introductions

 Introduction of Exercise Planners and Facilitators  Introduction of Participants, Subject Matter Experts, Department Officials and Media  Housekeeping Issues  Agenda Review 3

Exercise Purpose

To evaluate current response concepts, plans, and capabilities related to a medical surge of patients from a foodborne illness outbreak in the local community. The exercise will focus on the coordination of surveillance activities and health system capabilities anticipated when managing a medical surge among community healthcare partners. 4

2013 Statewide Medical and Health Exercise Target Capabilities

5  Emergency Operations Center Management  Medical Surge  Communications  Emergency Public Information and Warning  Public Health Epidemiological Surveillance

Tabletop Exercise Objectives

Exercise Planners may insert organization/agency specific objectives found in the Situation Manual beginning on page 3, may customize objectives consistent with the tabletop exercise questions or may delete this slide. The following slides can be edited according to the objectives used.

(Yellow font color signifies the need for customization by the organization/agency) 6

Tabletop Exercise Objectives

1. Evaluate the ability to utilize redundant communication modalities and processes internally and externally per policies and procedures within the exercise timeframe.

2. Evaluate the ability of medical and health partners to activate surge plans within established protocols.

3. Evaluate the ability of medical and health partners to participate in the California Statewide HAvBED poll within one hour of the initial notification.

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Tabletop Exercise Objectives

4. Evaluate the ability of medical and health partners to utilize California Public Health and Medical Emergency Operations Manual (EOM) format and/or local situation status reporting format to exchange and share event situational intelligence/awareness within the exercise timeframe.

5. Evaluate the ability to implement the Incident Command System (ICS) in response to a foodborne illness.

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Tabletop Exercise Objectives

6. Evaluate the ability of medical and health partners to develop an Operational Period Action Plan (AP) and conduct associated briefings.

7. Evaluate the ability of medical and health partners to request, distribute, track, and return resources in accordance with the California Public Health and Medical Emergency Operations Manual (EOM), to include allocation of scarce resources.

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Tabletop Exercise Objectives

8. Evaluate the ability of medical and health partners to validate and coordinate risk communication between command centers/operations centers and partners during exercise play (i.e., Emergency Operations Center, Nursing Home Command Center, Hospital Command Center, Department Operations Center).

9. Evaluate the ability of medical and health partners to issue public information, alerts, warnings, and notifications through established systems to patients, staff, the public, coordinating officials, incident managers and responders quickly and effectively.

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Tabletop Exercise Objectives

10. Evaluate the ability of local Public Health Departments to conduct surveillance and subsequent epidemiological investigations to identify potential exposure and disease.

11. In response to a notification of an existing threat of food contamination, evaluate the ability to implement necessary control measures to stop further cases of illness or disease in accordance with established policies.

Exercise Customization

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. (

This slide can be deleted once customization is done

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Exercise Customization

Response specific information and guidance may be accessed through subject matter experts including:  Public Health and communicable disease experts  Medical and Health Operational Area Coordinator  Mutual aid coordinators for medical, health, law enforcement and fire services  Communication partners (Include those resources for your exercise on this slide) 13

Exercise Ground Rules

 Do not fight the 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 14

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 15

Foodborne Illness Statistics

  

Each year in U.S. foodborne diseases cause:

9.4 million cases 55,961 hospitalizations 1,351 deaths

(Emerging Infectious Diseases. Volume 17, Number 1. January 2011)

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Background

What foodborne disease do these foods have in common?

 Raw sprouts  Pizza  Cookie dough  Fresh spinach  Ground beef patties  Romaine lettuce 17

Background Shiga Toxin producing E. coli:

 Gram negative bacteria  Considered normal flora in intestines  The incubation period is usually 3-4 days after the exposure, but may be as short as 1 day or as long as 10 days  Diarrhea (often bloody) and abdominal cramps  Little or no fever (less than 101 degrees Fahrenheit) 18

Impact of E. coli Outbreaks

A large outbreak of Shiga Toxin-producing E. coli infections linked to sprouts occurred in Europe in 2011, resulting in 3,950 cases.

 53 deaths (51 in Germany)  852 confirmed cases of hemolytic uremic syndrome (HUS) a type of kidney failure  Cases were reported in Germany, Switzerland, Poland, the Netherlands, Sweden, Denmark, UK, Canada and the USA 19 http://www.cdc.gov/ecoli/2011/ecoliO104/index.html

European Food Safety Authority

Impact of Recent E. coli Outbreak

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Multistate Outbreak of Shiga Toxin producing E. coli:

A total of 33 persons infected with Shiga Toxin producing

E. coli

were reported from five states  46% of ill persons were hospitalized. Two ill persons developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths were reported  Traceback investigations of pre-packaged leafy greens purchased by ill persons http://www.cdc.gov/ecoli/2012/O157H7-11-12/index.html

Impact of Recent E. coli Outbreak

Multistate outbreak of E. coli infections linked to ground beef patties:

21  Several state health departments, CDC, and the United States Department of Agriculture’s Food Safety and Inspection Service investigated a multi-state outbreak of issued.

E. coli

infections. As a result, a recall of 21.7 million pounds of frozen ground beef patties was  Health officials found many ill persons had consumed the same brand of frozen ground beef patties. Opened and unopened packages of patties recovered from patients' homes yielded

E. coli

.

Tabletop Exercise

 The exercise consists of four modules plus an addendum for planning the November 21, 2013 Functional Exercise.

 Each module will identify the 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.

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Scenario

On November 18, 2013, health care providers at community health centers, private physician ’s offices and local emergency departments began seeing previously healthy patients with complaints of abdominal pain throughout (Organizations/Jurisdiction can fill in location) County. 23

Scenario (Continued)

Within one day cases of bloody diarrhea had been reported by

(

Organizations/Jurisdictions can fill in number) health care providers at community health centers, private physician ’s offices and local emergency departments in the county. Two days after the first reports of abdominal pain and bloody diarrhea,

(

Organizations/Jurisdictions can fill in number ) patients were admitted to the Intensive Care Unit with symptoms of decreased urine output, lethargy and persistent bloody diarrhea. 24

(

Organizations/Jurisdictions can fill in number) patients were diagnosed with hemolytic uremic syndrome. Cases presenting similar symptoms continue to be reported throughout the county.

Scenario (Continued)

Five days after the first reported case,

(

Organizations/Jurisdictions can fill in number) patients have been identified with similar presenting symptoms at local hospitals, community health centers and private physician practices.

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Module 1: Emergency Operations Center Management and Medical Surge

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Key Issues:

 Response is coordinated through the use of Incident Command System principles and Command Centers/Emergency Operations Centers  Action Plans are developed to guide and document the response and recovery phases  Activation of Surge Plans  Request and/or response to resource requests

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Questions for Discussion

(Jurisdictions can edit which questions they want to include)

1. 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?

2. How is your Command Center/Emergency Operations Center activated to support Incident Command System operations? Does the activation process utilize a written plan?

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Questions for Discussion

3. How are key partners notified of activation? What time frame is the notification communicated in?

4. How does your organization/jurisdiction communicate and share information with other members of the incident management team or Command Center/Emergency Operations Center personnel? How is information transfer validated? Is there a policy and procedure that covers this? If procedures are in place, is the process regularly tested?

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Questions for Discussion

5. 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?

6. How do you plan for an influx of patients including the access and functional needs population? What types of services can be altered, postponed or relocated to other sites? Have clinical providers been active in the decision making for alteration of services?

Questions for Discussion

7. What is the operational area plan during a medical surge, including the access and functional needs population? How does the plan address mutual aid? How does the plan coordinate from local to regional to State level? 8. Which partner organizations can assist in providing services that you must alter or suspend due to a medical surge? Do you have Memoranda of Understanding signed with these partner organizations?

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Questions for Discussion

9. What is the operational area resource requesting process? What is the operational area process to request resources to the region or the State? Are these processes regularly tested?

10. How do you request, respond to, distribute, track and/or return resources in accordance with the California Public Health and Medical Emergency Operations Manual?

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Module 2: Communications and Public Information and Warning

Key Issues:

 Internal and external communication between key response partners 32  Use of redundant communication modalities  Utilize California Public Health and Medical Emergency Operations Manual and/or local situational intelligence/awareness within the exercise timeframe

Questions for Discussion

1. What is your role in receiving and disseminating critical information internally and externally?

2. What mechanisms and/or technology are in place to receive and disseminate information internally and externally? 3. How does your organization/jurisdiction participate in a Joint Information System?

4. How would you share your agency ’s information with the Joint Information System? Who approves information to be shared?

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Questions for Discussion

5. What is your plan to notify staff, patients, clients, and/or stakeholders of a foodborne illness event? What individuals or groups require notification? What are the communication methods to disseminate this information and the safety measures to be taken during a medical surge due to foodborne illness? How is communication coordinated between Infection Preventionists, Disaster Coordinators and the local health department?

34 6. How does your organization/agency use social media to disseminate information?

Module 3: Emergency Public Information and Warning

Key Issues:

 Risk communication messaging is developed within the operational area Joint Information System  Policy and procedure for dissemination of key messages is established within the facility/agency/department 35

Questions for Discussion

1. How are public information and warning updates coordinated with local, state, and federal agencies? How does your organization/agency coordinate risk communication between command centers/operations centers, and partners during medical surge? How does your organization/agency handle conflicting guidance from different local, state and federal agencies?

2. How are public information and warning updates disseminated?

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Questions for Discussion

3. What is your risk communication plan for media inquiries prior to an official press release being issued? When does notification go out to local health departments, health care providers and the public?

4. How is risk communication addressed? What modalities and redundant methods are used?

5. How does your organization/agency utilize public hotlines to provide information? 37

Scenario (Continued)

Laboratory staff have requested guidance from the local health department on appropriate protocols for specimen collection and laboratory techniques to confirm the diagnosis. Health care facilities are requesting guidance on necessary levels of isolation and personal protective equipment requirements for staff. 38

Scenario (Continued)

Ambulance companies are reporting an increase in call volume and extended delays in offloading patients at local emergency departments. Hospitals are experiencing continuing surge with increasing emergency department wait times. The initial epidemiologic investigation has not revealed a consistent pattern of age, race, occupation, geographic distribution or previous symptomatology among patients which might indicate a source of the offending agent. 39

Module 4: Public Health Epidemiological Surveillance and Investigation

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Key Issues:

 Epidemiological surveillance and investigation coordinated with the health care partners  Implement control measures

Questions for Discussion

1. Which state and local authorities would provide information and guidance regarding the Shiga Toxin-producing

E. coli

outbreak? Do you have 24/7 contact information for these authorities?

2. What actions would you take to communicate with the public health authorities if a patient presents with a suspected foodborne disease? 41

Questions for Discussion

3. Beyond health care providers, who else does the local health department communicate with if they see an increase in certain disease syndromes?

4. When and how would your organization/agency be made aware of an increase in Shiga Toxin producing

E. coli

isolates within your jurisdiction? Are there multiple modes of communication for this kind of information? 42

Questions for Discussion

5. What would prompt an investigation, and who would undertake the investigation and analysis if an outbreak were to occur in your jurisdiction? 6. How systematic is the collaboration between your organization/agency and the laboratories to influence prioritization of work? What rules or processes govern this relationship?

7. How are control measures issued by public health? How are the control measures issued by public health implemented?

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Conclusion of Discussion-Based Tabletop

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Planning for the November Functional Exercise

The scenario will be a medical surge due to foodborne illness.

Customization of the exercise allows incorporating other objectives as needed. Examples include issues identified in past exercises, new training or equipment, or new policies and procedures.

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Planning for the November Functional Exercise

Note:

Not all organizations and/or agencies will use the scenario of a medical surge due to foodborne disease as the basis for the November 21, 2013, Functional Exercise. The provision of mutual aid to affected areas may be used as the scenario to launch the actions and activities undertaken during the exercise.

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November Exercise Issues for Discussion

Exercise Level of Play:

 What level of exercise play do the organizations/agencies represented today anticipate for the November 21, 2013 exercise?  Examples include communications drill, functional and full scale exercises, level of play may include use of simulated patients, movement of patients to healthcare facilities, activation of the joint information center, provision of mutual aid, etc.

 Will your organization/agency activate its Command Center/Emergency Operations Center?

Issues for Discussion

Exercise Times/Duration:

 Exercise play is being developed to include a message to begin the exercise. Participants may begin exercise play at their discretion but are strongly encouraged to collaborate with local/operational area partners  Can participants estimate their hours of exercise play at this time? 48

Issues for Discussion Exercise Customization:

 Discuss organization/agency impacts from a medical surge due to foodborne disease  Identify additional areas of impact for epidemiological surveillance  Ensure exercise customization is included in the Master Scenario Events List 49

Issues for Discussion

Exercise Customization (Continued) Testing of Policy and Procedures:

• Are there any plans, policies or procedures which individual departments or organizations/agencies would like to test? Examples include: utilities management, patient surge, fatality response, continuity of operations plans, etc.

• Identify the plans to be tested that should be included in the customization of the Master Scenario Events List 50

Role of State Agencies

On November 21, 2013, the California Department of Public Health and the California Emergency Medical Services Authority will open the Medical and Health Coordination Center (Formerly the Joint Emergency Operations Center). 51 The California Emergency Management Agency is anticipated to participate by opening the State Operations Center and the Regional Emergency Operations Centers to support local and regional exercise play. This will provide the opportunity for local participants to request additional resources, submit and receive situation status reports and respond to California Health Alert Network (or other notification systems) messages and receive further direction.

Thank You For Your Participation

Additional materials may be found on:

California Statewide Medical and Health Training and Exercise Program website:

www.californiamedicalhealthexercise.com

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