Transcript Document 7296151

[Hospital Logo]
[Hospital Name]
Bioevent Tabletop Exercise
Moderated by:
and
Facilitated by:
[Local Health Department Logo]
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Exercise Objectives
• Increase bioevent awareness
• Assess level of hospital preparedness and ability to respond during a
public health emergency
• Explore surge capacity issues for increasing staffed beds, isolation rooms
and hospital personnel
• Evaluate effectiveness of incident command system policies, procedures
and staff roles
• Discuss the psychosocial implications of a bioevent and the role of mental
health assets
• Update and improve the emergency management plan from lessons
learned during the tabletop exercise
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Exercise Format
• This is an interactive facilitated tabletop exercise with three
modules.
• There are breakout group sessions after the first two modules,
which are both followed by a moderator facilitated discussion
with each breakout group reporting back on the actions taken.
• After the third and final module there is a facilitated plenary
discussion with all participants.
• A Hot Wash (debriefing) is the final component of the exercise
followed by an exercise evaluation.
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Breakout Groups
• There are three (four) groups for the breakout
sessions:
• Administration
 EOC/Incident Command
• Clinical services  Operations
• Ancillary services  Logistics
• Infection Control/Epidemiology
• Each participant has been assigned to a group
• Interaction between groups is strongly encouraged
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Rules of The Exercise
• Relax - this is a no-fault, low stress environment
• Respond based on your facility's current capability
• Interact with other breakout groups as needed
• Play the exercise as if it is presently occurring
• Allow for artificialities of the scenario – it’s a tool and
not the primary focus
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Hospital
[Your institution]
• Certified beds –
• Staffed beds –
[Graphic of
your facility]
• Staff – FTEs
• ED visits –
• Airborne Infection
Isolation Rooms –
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Module One
Recognition
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[Season] in [Local area]
• Current weather –
(December –April)
• Used to set the scene –
(would suggest flu
season) time of year
etc.
• Graphics depicting local
area e.g. Manhattan,
Bronx, etc.
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[Day 1] at 11:00 am
• A 33-year-old man (David) arrives at the ED
complaining of fever with chills, a persistent cough,
body aches and loose stools.
• He complained of having the “stomach flu” for two
days.
• He is triaged in the ED and returns to the waiting room
for an hour before he is called back into an exam area.
• On exam his vital signs are temperature 101.2F, BP
96/50, HR 108, Oxygen saturation of 92% on room air,
and RR 24 with crackles at the right base.
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[Day 1] at 3:00 pm
• His chest X-ray shows possible
bilateral pleural effusion and he is
placed on oxygen & started on IV
Ceftriaxone and Azithromycin.
•The admitting team diagnosis is
community-acquired pneumonia.
•The patient’s inpatient bed does
not become available until almost
10:00 pm.
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[Day 2] at 9:00 am
• The ED has approximately [12] people waiting to be seen for
complaints of fever, cough and general malaise.
• They are between the ages of 21 and 35 years old.
• [Six] patients have already been admitted for communityacquired or atypical pneumonia since yesterday.
• The infection control team is not aware of the admissions.
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[Day 2] at 9:00 am
• David’s fiancé (Donna) is at the
bedside and reports that she has had a
cough, headache and myalgia for 7
days but has felt well enough to
continue working.
•She is a nurse in the Medical ICU and
has stopped by to visit.
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[Day 2] at 4:00 pm
•Donna is at the bedside of her fiancé and
she has now developed worsening chills
and a fever.
•She goes home to rest and will stop by to
visit in the morning before she starts her
day shift.
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[Day 3] at 7:00 am
• [Three] RNs (including Donna) and [2]
Nursing Aides scheduled for the day shift
in the Medical ICU call out sick.
• The [two] Respiratory Therapists that
cover the Medical ICU call off sick.
• An Environmental Service employee for
the day shift in the Medical ICU is
complaining of chills and temperature.
She decides to go home one hour after
arriving at work.
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[Day 3] at 5:00 pm
•The ICU Nursing Director contacts the VP of
Clinical Services for approval to call agency
nurses
• [25%] of the staff have called out with flu like
illness and [5] ICU patients have developed new
onset fevers
• The VP of Clinical Services also receives a
phone call from the Respiratory Therapy director
• [4] of the Respiratory Therapists have called out
sick and they need to request help from a
temporary agency
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[Day 3] at 9:00 pm
•David develops acute respiratory failure requiring
intubation and mechanical ventilation.
• An infectious disease consultation is called.
•The on-call pulmonologists perform a bronchoscopy and a
bronchial alveolar lavage at the bedside.
• All cultures and stains are nondiagnostic.
• His clinical status deteriorates and he expires at
7:45 pm.
• Donna has been admitted for atypical pneumonia.
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Situation Report #1
[Specify dates for Days 1-3]
• Total patients with flu-like/respiratory illness:
• Patients admitted
• Seen In ED
[10]
[25]
• Fatalities
[1]
• # HCWs ill:
[22]
• Total available beds by department:
•
•
•
•
•
[8] Adult Medical/Surgery
[3] Pediatric Medical/Surgery
[1] ICU
[2] Telemetry
[6] Other
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Module One
Breakout Group Discussion
• Are you experiencing an outbreak ?
• Would your emergency response plan/EOC
be activated?
• Describe specific communication needs and
how to address them.
• Who and when do you notify partners
(internal and external)?
• What are your staffing, bed, infection control,
supply, and environmental needs at this
point?
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First Breakout Group
Report Back
Module Two
Response
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[Day 3] at 11:00 pm
• Earlier this evening, the CDC learns that
clusters of atypical pneumonia are being
reported from southern China.
• The evening news is reporting the World
Health Organization (WHO) teams are
traveling to southern China to evaluate
possible SARS-like illness.
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[Day 4] at 8:30 am
• The hospital Infection Control Practitioner
(ICP) notifies the [Local DOH] this morning
at 7 am about the 33-year-old male fatality
and the unusual numbers of healthcare
workers out with respiratory illness.
• The ICP also reports that David’s fiancé
(Donna) is now admitted with the same
symptoms.
• Donna recently visited China with her sister
and returned eleven days ago.
• The ICP reports that several ill employees
seem to have had prior contact with Donna.
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[Day 4] at 11:00 am
• The Department of Health Medical Epidemiologist
comes to your facility to review cases and interview
Donna.
• Blood and Nasopharyngeal swab specimens from
David and Donna are split and sent to the Public
Health Lab and CDC.
• Patients with a diagnosis of atypical, community
acquired pneumonia or acute respiratory illnesses are
placed on Isolation Precautions and specimens are
obtained for testing.
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[DOH] Health Alert Issued
Year] ALERT #38: Suspected Case of Severe Acute Respiratory Illness alert in [Your City].
Please Distribute to All Medical, Pediatric, Family Practice, Laboratory, Critical Care, Pulmonary, Dermatology,
Employee Health, and Pharmacy Staff in Your Hospital
Dear Colleagues:
A previously healthy 33-year-old woman who had visited China less than 11 days ago has developed an
unidentified respiratory illness. Her previously healthy male partner has expired from a similar respiratory
illness. The [Your City] DOH, and the federal Centers for Disease Control and Prevention (CDC) are currently
conducting epidemiologic and laboratory investigations. The [your city] DOH is requesting heightened
surveillance for persons presenting with the following illness:
1. High fever (>38o C or 101.4o F) AND
2. Respiratory signs or symptoms, including cough, shortness of breath or difficulty breathing AND/OR
3. Anyone with these symptoms who has traveled to Asia or had contact with someone who has been to
Asia or works as a healthcare worker.
[Local DOH] requests immediate reporting of any cases with the above illness….
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[Day 4] at 3:30 pm
• The Vice President of Clinical
Services reports that 10-20% of
nursing personnel have called out
sick for the night shift as have
numerous house staff and
physicians.
• [Four] patients who had recently
been in Labor & Delivery are
returning with complaints of fever
and respiratory illness.
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Laboratory Results
[Day 4] at 9:00 pm
• Preliminary testing at the Public Health
Laboratory (ELISA and RT-PCR) on
specimens from the 33-year-old male
and his fiancé are found to be positive
for the SARS coronavirus.
[Day 5] at 9:00 am
• CDC is now confirming SARS-CoV in
specimens sent by the PHL for
confirmation.
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[Day 5] at 9:00 am
• Based on reports of
suspected or confirmed
SARS cases in [Your City]
as well as in China and
several other countries, the
WHO and CDC issue an
international health alert.
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Government Agency Responses
• Joint press conference is conducted with the Mayor, DOH and hospital
• Emergency Operation Center (EOC) activated.
• [DOH] initiates active surveillance and contact investigations citywide
and at [your] hospital.
• The DOH assigns a senior medical epidemiologist as full time liaison to
[your] hospital.
• Frequent mayoral and DOH press briefings to address public concerns.
• DOH maintains provider and public hotlines, and conducts daily
conference calls with all city hospitals to provide updates on the
outbreak
• DOH monitors hospital bed capacity and staffing/supply needs citywide
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Situation Report #2
[Specify dates for Days 1-5]
• Total Suspect and Confirmed SARS cases at your
hospital:
• [43] patients admitted
• [4] in ED
• [8] admitted to ICU
•
•
•
•
Total worried well in ED: [~65]
Fatalities: [1]
# of HCWs among SARS cases: [39]
Total available beds by Department
•
•
•
•
[0] Adult Medical/Surgery
[0] Pediatric Med/Surgery
[0] ICU
[2] Other
• No other hospitals in the area have been affected
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Module Two
Breakout Group Discussion
• How will you handle the increasing number of ill?
Worried well?
• Where and how will you set up triage?
• How will you identify and handle exposed employees
who are ill? Who are asymptomatic?
• Where will you house all the patients needing Airborne
Infection Isolation Rooms?
• What supply and materials management issues will be
critical to address?
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Second Breakout Group
Report Back
Break
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Module Three
Surge Capacity
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[Day 8] at 9:00 am
(1 week later)
• [Three] employees, (1 nurse, 1
respiratory therapist and a resident)
who assisted with the intubation of
David are admitted to the ICU.
• All have acute respiratory distress
syndrome and sepsis.
• The on-call pulmonologist who
performed the bedside bronchoscopy
on David has expired from respiratory
distress syndrome.
• Several household members of
infected HCWs are in the ED
complaining of flu-like illness.
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[Day 8] at 10:00 am
• All AIIRs are full.
• There are no additional ICU beds and
all ventilators are in use.
• Your hospital’s Emergency
Department is on diversion (bypass)
and filled with concerned individuals
and persons with febrile illness.
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Epidemiologic Investigation
• Donna is recovering but 3 of her family contacts have
developed febrile respiratory illness and two are
hospitalized with pneumonia.
• Although many of the cases at [Your Hospital] were
traced to either an exposure to David or Donna, 30%
of healthcare worker cases were not.
• Case finding identified a patient who had been
admitted with community acquired pneumonia two
weeks ago and placed on Standard Precautions.
• He received several nebulizer treatments while hospitalized
• The patient was contacted at home and reported that he had
traveled to China to visit his mother in the hospital.
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[Day 8] at Noon
•The local midday news on Channel [?] reports an increase in
cases of acute respiratory illness with flu-like symptoms that
are being seen in several clinics and other EDs in the city.
•EDs are particularly crowded today - there are reports that
many hospital employees have become ill.
•[Your Facility’s] phone lines are jammed with people calling
for information and to make clinic appointments for tomorrow
AM. Callers are becoming irate at the long phone wait times
to speak with hospital personnel about their concerns.
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[Day 8] at 3:00 pm
• The numbers of healthcare
providers reporting in sick and
those seeking care from other
area hospitals is increasing.
• Major local and national news
channels are running
continuous coverage of the
events.
• Subject matter experts are
speculating that this outbreak of
SARS may be worse than
Toronto 2003.
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[Day 8] at 4:00 pm
• Area hospitals, clinics and doctors’ offices are
reporting a large influx of patients throughout the day
who are convinced that they have been exposed to
SARS.
• Other people, who are extremely ill, are refusing to go
to the hospital as they are convinced that most
exposures occur there. They quote the Toronto
experience.
• Daycare providers and schools are receiving calls from
parents who are concerned about letting children of
health care workers from affected hospitals attend
classes.
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[Day 9] at 9:00 am
• There have been 3 more
fatalities related to SARS
at your hospital.
Attention is focusing on
planning for the
possibility of increased
fatalities, in the event that
hospital morgues
become full.
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Situation Report #3
[Specify dates for Days 1-9]
• Total suspect and confirmed SARS cases at your
facility:
• [#] patients admitted
• [#] in ED
•
•
•
•
Total worried well in ED: [~#]
# of HCWs among SARS cases: [#]
Fatalities: [#]
Total available beds by Department
•
•
•
•
[#] Adult Medical/Surgery
[#] Pediatric Med/Surgery
[#] ICU
[#] Other
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Module Three
Group Discussion
• How does your Emergency Response Plan address the need
for surge capacity?
• How are conducting screening at facility entrances?
• How are you communicating with staff, patients, and families?
• What type of support are you providing for staff being
isolated/quarantined at home?
• How are you dealing with staff fatigue? Mental health issues?
• What might you have done differently earlier in the outbreak?
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Hot Wash
• What have you learned during this tabletop exercise?
• What are the hospital’s Emergency Preparedness
strengths?
• What are the weaknesses / gaps of the Emergency
Preparedness Plan?
• What should the hospital’s next steps in
preparedness be?
• List and prioritize five short and long-term actions for
follow-up.
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Thank you!
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