[Hospital Name]

1. 1  [Hospital Name]   Suggested Moderator Speaking Points: Introduce yourself – give a thumbnail sketch of your credentials Briefly explain the rationale for conducting this exercise and define a tabletop Define the term bioevent – emerging infectious disease either naturally occurring or intentional in nature. Suggested Moderator Speaking Points: Introduce yourself – give a thumbnail sketch of your credentials Briefly explain the rationale for conducting this exercise and define a tabletop Define the term bioevent – emerging infectious disease either naturally occurring or intentional in nature.

2. 2 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 Identify triggers for activating the incident command system 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 revise the emergency management plan from lessons learned during the tabletop exercise Exercise Objectives Instructions to Moderator: The objectives may be adjusted to meet the needs of your exercise and facility (e.g., you may be testing the capability of a specific department, a specific shift or you may be focusing on surge capacity, triage, disease recognition, laboratory diagnosis, screening and isolation of patients coming to the emergency department, case-finding within the hospital and/or mental health aspects). Instructions to Moderator: The objectives may be adjusted to meet the needs of your exercise and facility (e.g., you may be testing the capability of a specific department, a specific shift or you may be focusing on surge capacity, triage, disease recognition, laboratory diagnosis, screening and isolation of patients coming to the emergency department, case-finding within the hospital and/or mental health aspects).

3. 3 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 is the final component of the exercise followed by an exercise evaluation. Instructions to Moderator: There are 2 options for conducting the exercise (See Chapter 2 for details), including: 1. Breakout Group Format: Participants assemble into breakout groups after Modules 1 and 2 to discuss probable actions based on their facilities’ and specific departments’ plans, policies, and procedures. The breakout groups reconvene to share key points/actions taken with the entire group. After the third module, there is a facilitated plenary discussion with all participants. (Slide 3 reflects this option). 2. Single Group Format: After each module, the Moderator facilitates the discussion session in a large group format, without breaking into smaller groups. The moderator can use questions from Appendix 5 - “Generic Questions for Moderator and/or Facilitators” - to lead the discussion sessions. If you use this option, Slide 3 should be edited to reflect this format. EOC Option (Can be used with either of the above formats): Before the breakout or single group discussion, convene the members of the EOC/Incident Command group at the front of the room and have them openly deliberate for 5-10 minutes about the current status of the outbreak and prioritize the issues for the participants to address during the breakout group or single group discussion, much as an actual EOC would function. Suggested Moderator Speaking Points: Describe format chosen for the tabletop exercise If using breakout groups, Introduce facilitators for each group. Define “Hot Wash” - A “Hot Wash” is an open discussion at the end of the exercise allowing participants to provide instant feedback about immediate lessons learned and to identify barriers/gaps in current emergency management plans and procedures. Instructions to Moderator: There are 2 options for conducting the exercise (See Chapter 2 for details), including: 1. Breakout Group Format: Participants assemble into breakout groups after Modules 1 and 2 to discuss probable actions based on their facilities’ and specific departments’ plans, policies, and procedures. The breakout groups reconvene to share key points/actions taken with the entire group. After the third module, there is a facilitated plenary discussion with all participants. (Slide 3 reflects this option). 2. Single Group Format: After each module, the Moderator facilitates the discussion session in a large group format, without breaking into smaller groups. The moderator can use questions from Appendix 5 - “Generic Questions for Moderator and/or Facilitators” - to lead the discussion sessions. If you use this option, Slide 3 should be edited to reflect this format. EOC Option (Can be used with either of the above formats): Before the breakout or single group discussion, convene the members of the EOC/Incident Command group at the front of the room and have them openly deliberate for 5-10 minutes about the current status of the outbreak and prioritize the issues for the participants to address during the breakout group or single group discussion, much as an actual EOC would function. Suggested Moderator Speaking Points: Describe format chosen for the tabletop exercise If using breakout groups, Introduce facilitators for each group. Define “Hot Wash” - A “Hot Wash” is an open discussion at the end of the exercise allowing participants to provide instant feedback about immediate lessons learned and to identify barriers/gaps in current emergency management plans and procedures.

4. 4 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 Instructions to Moderator: This slide should be deleted if the Single Group format is chosen If the Breakout Group format is chosen, the “Infection Control, Epidemiology and Laboratory Services” group may be added as a fourth breakout group or included within operations (Clinical Services). Please refer to Appendix (1a and 1b), “Breakout Groups” for suggested groups of player participation. Instructions to Moderator: This slide should be deleted if the Single Group format is chosen If the Breakout Group format is chosen, the “Infection Control, Epidemiology and Laboratory Services” group may be added as a fourth breakout group or included within operations (Clinical Services). Please refer to Appendix (1a and 1b), “Breakout Groups” for suggested groups of player participation.

5. 5 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 Instructions to Moderator: Delete 3rd bullet if Single Group format is used. Instructions to Moderator: Delete 3rd bullet if Single Group format is used.

6. 6 Hospital[Your institution] Certified beds – Staffed beds – Staff – FTEs ED visits – Airborne Infection Isolation Rooms (AIIRs)– Instructions to Moderator: Insert your hospital name and the number of available certified beds, staffed beds, FTEs (you may want to divide this between clinical and non-clinical if the information is available from your finance department), annual or monthly ED visits, and number of Airborne Infection Isolation Rooms available in your facility. You may also add the number of ICU beds, OR Rooms, etc. Instructions to Moderator: Insert your hospital name and the number of available certified beds, staffed beds, FTEs (you may want to divide this between clinical and non-clinical if the information is available from your finance department), annual or monthly ED visits, and number of Airborne Infection Isolation Rooms available in your facility. You may also add the number of ICU beds, OR Rooms, etc.

7. 7 Suggested Moderator Speaking Points: The first module focuses on disease recognition and the steps that the hospital must take in the earliest phase of a suspected outbreak.Suggested Moderator Speaking Points: The first module focuses on disease recognition and the steps that the hospital must take in the earliest phase of a suspected outbreak.

8. 8 [Season] in [Local area] Current weather (hot/cold) Used to set the scene – time of year etc. Graphics depicting local area e.g. Manhattan, Bronx, etc. Instructions to Moderator: This slide should be customized for your area. You may want to use a season when influenza is not expected (e.g., summer). Instructions to Moderator: This slide should be customized for your area. You may want to use a season when influenza is not expected (e.g., summer).

9. 9 [Day One] at 3:30 pm The emergency department is busy as usual Exam rooms are filled, staff are busy, tensions are high Wait times for non-emergent patients is exceeding [six] hours. Getting patients admitted to a room seems to be taking longer than usual Ambulance traffic is steady – the midday backup of vehicles is taking its toll Instructions to Moderator: Optional: replace “Day One” with date and day of week on this slide and continue to do so on subsequent slides. Adjust “waiting time” for non-emergent patients to exceed your average daily waiting time. Instructions to Moderator: Optional: replace “Day One” with date and day of week on this slide and continue to do so on subsequent slides. Adjust “waiting time” for non-emergent patients to exceed your average daily waiting time.

10. 10 [Day One] at 3:30 pm A 36 year-old man arrives at the ED by ambulance from [local outpatient clinic] to be admitted for pneumonia. He’s complaining of fever, chills, nausea, and general malaise. On exam his vital signs are temp 101.2oF, HR 108, BP 96/50, O2 saturation 93% on room air, and RR 24 with crackles at the right base.

11. 11 [Day One] at 6:30 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 4:00 am. Instructions to Moderator: Some of the bullets may be asked directly to the Emergency Medicine staff; however, limit time on clinical information and focus on emergency preparedness: What tests would you order? If and if so, what antibiotics would you order for this patient? Would you discharge or admit this patient? If, and if so, what infection control and isolation precautions would you take? Instructions to Moderator: Some of the bullets may be asked directly to the Emergency Medicine staff; however, limit time on clinical information and focus on emergency preparedness: What tests would you order? If and if so, what antibiotics would you order for this patient? Would you discharge or admit this patient? If, and if so, what infection control and isolation precautions would you take?

12. 12 [Day Two] at 6:30 am During morning rounds the medical team finds that throughout the previous night, the patient had continuous fever of 102 oF and several episodes of vomiting. On exam he has worsening respiratory function, increasing lethargy, and there is a question of nuchal rigidity.

13. 13 [Day Two] at 6:30 am The patient’s sister states that her brother has been previously well with no history of medical problems. He’s traveled both domestically and internationally on political advocacy business. He arrived in [Name of your city] to visit his sister four days ago from Denver.

14. 14 [Day Two] at 7:30 am The case is presented during rounds and the attending requests that a lumbar puncture be done immediately When the resident goes into the patient’s room to prep him, he finds the patient extremely short of breath with an O2 sat of 82% on 5 liters of oxygen He’s emergently intubated and moved to the ICU He later becomes hypotensive, codes and dies The patient’s family agrees to a post-mortem

15. 15 [Day Two] at 8:30 am Admissions from the ED are lining the hallway; wait time for inpatient beds is averaging [12 hours]. [Fifteen] patients are awaiting admission: [10] with pneumonia, two of whom are six year-old twins, whose parents are extremely anxious; [3] with chest pain; and [2] trauma patients requiring surgical beds. [Four] ED nurses scheduled for the morning shift call in sick. Instructions to Moderator: Adjust wait time to be twice your average wait times Number of patients awaiting admission can be adjusted for your facility to imply a large number of patients with pneumonia as well as patients with everyday problems – chest pain, trauma, pregnancy etc. Adjust number of ED nurses to equal a 15-20% absenteeism rate based on your normal morning shift depending on which day of the week you use. Consider asking the following questions: Is it likely that this is a localized occurrence in this ED? Is it unusual that four ED nurses from one shift call in sick? Would anyone question whether their illnesses might be related? Instructions to Moderator: Adjust wait time to be twice your average wait times Number of patients awaiting admission can be adjusted for your facility to imply a large number of patients with pneumonia as well as patients with everyday problems – chest pain, trauma, pregnancy etc. Adjust number of ED nurses to equal a 15-20% absenteeism rate based on your normal morning shift depending on which day of the week you use. Consider asking the following questions: Is it likely that this is a localized occurrence in this ED? Is it unusual that four ED nurses from one shift call in sick? Would anyone question whether their illnesses might be related?

16. 16 [Day Two] at 2:00 pm The ICU attending is watching the local news on Channel [4] in a patient’s room while waiting for him to return from X-ray. She hears [local reporter’s name] reporting on the death of a city official from an acute respiratory illness. The aide to this official is in the ICU at [other local hospital] with a respiratory illness and is listed in serious condition.

17. 17 [Day Two] at 2:15 pm A few minutes later the ICU attending is paged by the ED resident. [Six] of the [ten] pneumonia patients in the ED, including 6 y.o. twins, require ICU admission. All are hypotensive with fever and shortness of breath; intubation anticipated or underway for all [six]. Nurses are starting to talk amongst themselves about the cases and speculation is rife. Instructions to Moderator: Consider asking the following question: Would the local health department be consulted at this point? Instructions to Moderator: Consider asking the following question: Would the local health department be consulted at this point?

18. 18 Total suspect: [10] patients admitted [4] to ICU [2] to Pediatric ICU Total worried well in ED: [~50] Fatalities: [1] Total available beds by Department [5] Adult Medical/Surgery [3] Pediatric Med/Surgery [1] ICU [12] Other Instructions to Moderator: The numbers in this report should be a 10-15% surge in patient admissions and ED visits over normal baseline capacity by the end of Module 1. The number of available beds should reflect what is usual for your facility. Instructions to Moderator: The numbers in this report should be a 10-15% surge in patient admissions and ED visits over normal baseline capacity by the end of Module 1. The number of available beds should reflect what is usual for your facility.

19. 19 Module OneBreakout Group Discussion Instructions to Moderator: Ideally this session will run approximately 20-30 minutes. If using the EOC option: Ask the EOC/Incident Command members to convene at the front of the room and have them openly deliberate for 5-10 minutes about the current status of the outbreak and prioritize the issues for the participants to address during the breakout group or single group discussion, much as an actual EOC would function. If using the breakout group format: Remind groups to assign a recorder and/or reporter. Explain roles of each. You should circulate between the groups and, you can distribute injects as a tool to encourage the group if conversation lags or to provide extra pressure or unexpected elements for more sophisticated groups. Injects for each scenario are included in Chapter 5 of the exercise planning toolkit and are listed according to module and different breakout group categories. Give the facilitators a five minute warning so they can have the participants wrap up and have information ready to report back. If using the Single Group format: You should chose questions from Appendix 5 and direct these to the appropriate members of the audience to highlight key issues for the group discussion. Instructions to Moderator: Ideally this session will run approximately 20-30 minutes. If using the EOC option: Ask the EOC/Incident Command members to convene at the front of the room and have them openly deliberate for 5-10 minutes about the current status of the outbreak and prioritize the issues for the participants to address during the breakout group or single group discussion, much as an actual EOC would function. If using the breakout group format: Remind groups to assign a recorder and/or reporter. Explain roles of each. You should circulate between the groups and, you can distribute injects as a tool to encourage the group if conversation lags or to provide extra pressure or unexpected elements for more sophisticated groups. Injects for each scenario are included in Chapter 5 of the exercise planning toolkit and are listed according to module and different breakout group categories. Give the facilitators a five minute warning so they can have the participants wrap up and have information ready to report back. If using the Single Group format: You should chose questions from Appendix 5 and direct these to the appropriate members of the audience to highlight key issues for the group discussion.

20. First Breakout GroupReport Back Instructions to Moderator: If using the Breakout Group format: Ask each breakout group to report back on key issues raised and decisions made during their discussion. Use the questions in Appendix 5 to highlight other key issues that might not otherwise be discussed. If using the Single Group format: Delete this slide. Instructions to Moderator: If using the Breakout Group format: Ask each breakout group to report back on key issues raised and decisions made during their discussion. Use the questions in Appendix 5 to highlight other key issues that might not otherwise be discussed. If using the Single Group format: Delete this slide.

21. 21 Suggested Moderator Speaking Points: The second module is designed to simulate an escalating outbreak. Players should focus on the issues as they are presented and not “play ahead of the scenario”. Issues of patient triage, appropriate isolation, and prophylaxis should be addressed.Suggested Moderator Speaking Points: The second module is designed to simulate an escalating outbreak. Players should focus on the issues as they are presented and not “play ahead of the scenario”. Issues of patient triage, appropriate isolation, and prophylaxis should be addressed.

22. 22 [Day Three] at 8:30 am The hospital ICP notified the [Local DOH] yesterday afternoon regarding: The unusual number of severe respiratory cases presenting to the ED. A lab report indicating gram negative rods w/ bipolar staining from the blood cultures of the index case admitted on [Day One] [Local DOH] initiated an onsite epidemiological investigation, in coordination with FBI and [Local Police Department]. Specimens were sent to the [Bio-Threat Laboratory at the Local Public Health Lab]; a presumptive diagnosis was made for Yersinia pestis by PCR and DFA testing. The [Local DOH] contacted the Colorado Dept. of Health who were not able to identify any risk exposures for plague near the index case’s residence. Instructions to Moderator: Note that initial PCR rest results on clinical specimens require at least six hours once testing starts in the lab. Confirmatory testing will take an additional 18-24 hours. Instructions to Moderator: Note that initial PCR rest results on clinical specimens require at least six hours once testing starts in the lab. Confirmatory testing will take an additional 18-24 hours.

23. 23

24. 24 Summary of Public Health and Other Governmental Agency Responses Citywide Emergency Operations Center activated Press briefing with Mayor, Commissioner of Health and law enforcement agencies is held [Local DOH] initiates citywide active surveillance and epidemiologic investigation to determine common source and site of exposure. Daily citywide hospital conference calls provide clinical and epidemiological investigation updates

25. 25 [Day Three] at 9:30 am The [five] critical patients admitted to the ICU remain on vents, all have acute respiratory distress syndrome and sepsis. [One] of the pediatric ICU patients has expired All [five] patients are isolated and given IV antibiotics, fluids, and pressors. Several other pneumonia patients in ED awaiting admission are deteriorating and intubation is being contemplated for [four]. Many hospital employees are requesting antibiotic prophylaxis. Instructions to Moderator: The moderator may wish to ask the following questions of the audience after this slide: What kind of isolation precautions should have been instituted in the ICU? What kind of PPE should be worn by health care workers? How are you going to identify employees who were exposed to the plague patients? The following is for your information. Note that the appropriate isolation precautions for pneumonic plague are droplet and contact. Personal protective equipment would include: Surgical masks (N-95s are not needed) Gowns Gloves Eye covering, if splashing is anticipated Instructions to Moderator: The moderator may wish to ask the following questions of the audience after this slide: What kind of isolation precautions should have been instituted in the ICU? What kind of PPE should be worn by health care workers? How are you going to identify employees who were exposed to the plague patients? The following is for your information. Note that the appropriate isolation precautions for pneumonic plague are droplet and contact. Personal protective equipment would include: Surgical masks (N-95s are not needed) Gowns Gloves Eye covering, if splashing is anticipated

26. 26 Total suspect: [25] patients admitted [10] in ICU [15] in ED Total worried well in ED: [~65] Fatalities: [2] Total available beds by Department [5] Adult Medical/Surgery [2] Pediatric Med/Surgery [1] ICU [12] Other Instructions to Moderator: The number of available beds should decline markedly. Suggest at least a 30-35% surge in demand for each area of the hospital. Consider asking the following questions: How many ventilators would [your hospital] be able to access right away? Many hospitals rent ventilators from the same distributors. How difficult will it be to obtain additional vents under these circumstances? Would you be able to request additional ventilators from nearby hospitals? Instructions to Moderator: The number of available beds should decline markedly. Suggest at least a 30-35% surge in demand for each area of the hospital. Consider asking the following questions: How many ventilators would [your hospital] be able to access right away? Many hospitals rent ventilators from the same distributors. How difficult will it be to obtain additional vents under these circumstances? Would you be able to request additional ventilators from nearby hospitals?

27. 27 [Day Three] at 4:30 pm The Director of Nursing reports that [20%] of nursing personnel have called out sick for the night shift as have numerous house staff and physicians. Other [your city] hospitals are reporting similar staff shortages. House officer reports to work with fever and cough. Instructions to Moderator: Adjust the % of staff calling in sick in first bullet to place a moderate- severe level of stress on your facility. Instructions to Moderator: Adjust the % of staff calling in sick in first bullet to place a moderate- severe level of stress on your facility.

28. 28 Module TwoBreakout Group Discussion Instructions to Moderator: Ideally this session will run approximately 20-30 minutes. If using the EOC option: Ask the EOC/Incident Command members to convene at the front of the room and have them openly deliberate for 5-10 minutes about the current status of the outbreak and prioritize the issues for the participants to address during the breakout group or single group discussion, much as an actual EOC would function. If using the breakout group format: Remind groups to assign a recorder and/or reporter. Explain roles of each. You should circulate between the groups and, you can distribute injects as a tool to encourage the group if conversation lags or to provide extra pressure for more sophisticated groups. Injects for each scenario are included in Chapter 5 of the exercise planning toolkit and are listed according to module and different breakout group categories. Give the facilitators a five minute warning so they can have the participants wrap up and have information ready to report back. If using the Single Group format: You should chose questions from Appendix 5 and direct these to the appropriate members of the audience to highlight key issues for the group discussion. Instructions to Moderator: Ideally this session will run approximately 20-30 minutes. If using the EOC option: Ask the EOC/Incident Command members to convene at the front of the room and have them openly deliberate for 5-10 minutes about the current status of the outbreak and prioritize the issues for the participants to address during the breakout group or single group discussion, much as an actual EOC would function. If using the breakout group format: Remind groups to assign a recorder and/or reporter. Explain roles of each. You should circulate between the groups and, you can distribute injects as a tool to encourage the group if conversation lags or to provide extra pressure for more sophisticated groups. Injects for each scenario are included in Chapter 5 of the exercise planning toolkit and are listed according to module and different breakout group categories. Give the facilitators a five minute warning so they can have the participants wrap up and have information ready to report back. If using the Single Group format: You should chose questions from Appendix 5 and direct these to the appropriate members of the audience to highlight key issues for the group discussion.

29. Second Breakout Group Report Back Instructions to Moderator: If using the Breakout Group format: Ask each breakout group to report back on key issues/decisions made. Use the questions in Appendix 5 to highlight other key issues that might not otherwise be discussed. If using the Single Group format: Delete this slide. Instructions to Moderator: If using the Breakout Group format: Ask each breakout group to report back on key issues/decisions made. Use the questions in Appendix 5 to highlight other key issues that might not otherwise be discussed. If using the Single Group format: Delete this slide.

30. 30 Break Instructions to Moderator: Break can be adjusted to fit time available and can also be placed elsewhere in the slide set. Instructions to Moderator: Break can be adjusted to fit time available and can also be placed elsewhere in the slide set.

31. Module Three Instructions to Moderator: For the third module, the entire audience will assemble as a large group. There will no be no breakout groups. Depending on the size and composition of your audience, you may wish to ask some probing questions following selected individual slides in Module Three. Instructions to Moderator: For the third module, the entire audience will assemble as a large group. There will no be no breakout groups. Depending on the size and composition of your audience, you may wish to ask some probing questions following selected individual slides in Module Three.

32. 32 [150] patients with non-specific complaints and without fever are seeking medical attention. Wait time in the ED for non-emergent patients is still exceeding [12] hours. The hospital is operating at capacity. EMS is also extremely busy. Instructions to Moderator: Consider asking the following questions: How will these ambulatory non-plague related patients (e.g., broken leg) be triaged? What kind of mental health services may be provided? How will information about where to obtain antibiotic prophylaxis from the Local DOH clinics be distributed to patients? Instructions to Moderator: Consider asking the following questions: How will these ambulatory non-plague related patients (e.g., broken leg) be triaged? What kind of mental health services may be provided? How will information about where to obtain antibiotic prophylaxis from the Local DOH clinics be distributed to patients?

33. 33 [Day Four] at 2:00 pm Major local and national news channels are running continuous coverage of the events. The networks are speculating about the source of the outbreak and the risk for additional terrorism events in the city. Reporters are lined up outside the hospital asking staff and visitors for on-camera interviews. Instructions to Moderator: Consider asking the following questions: How will the hospital coordinate communicating to the media with the local Department of Health and other city agencies? How will you handle the press outside of your hospital? What information will you give the hospital staff about speaking with the press? Instructions to Moderator: Consider asking the following questions: How will the hospital coordinate communicating to the media with the local Department of Health and other city agencies? How will you handle the press outside of your hospital? What information will you give the hospital staff about speaking with the press?

34. 34 [Day Five] at 12:00 pm [Your hospital’s] emergency department and outpatient treatment areas continue to be swamped with persons seeking care and attention. Security measures have been initiated as waiting patients become more and more unruly. Patients are being told about the long wait times and that efforts are being made to seek alternative sites for their evaluation and treatment. Instructions to Moderator: Consider asking the following questions: What strategies will security use to manage the crowd around the emergency department and to secure entrances/exits? Instructions to Moderator: Consider asking the following questions: What strategies will security use to manage the crowd around the emergency department and to secure entrances/exits?

35. 35 [Day Five] at 12:00 pm Attention is focused on planning for the management of fatalities, given limited capacity in the hospital morgue Instructions to Moderator: Consider asking the following questions: What is the mortuary capacity in your hospital and what are the current plans for additional surge in this area? What do you do when morgue capacity is reached? What infection control precautions should mortuary staff take when handling the bodies? Instructions to Moderator: Consider asking the following questions: What is the mortuary capacity in your hospital and what are the current plans for additional surge in this area? What do you do when morgue capacity is reached? What infection control precautions should mortuary staff take when handling the bodies?

36. 36 Situation Report #3 [Day 1-5] Total suspect: [#] patients admitted [#] in ED [#] in ICU Total worried well in ED: [~#] Fatalities: [#] Total available beds by Department [#] Adult Medical/Surgery [#] Pediatric Med/Surgery [#] ICU [#] Other Instructions to Moderator: Final numbers for the outbreak should be provided here. Numbers should reflect tallies provided on previous slides. The total cases and fatalities are only those at your facility, not citywide numbers. Suggest using numbers that represent a > 40-50% surge for your hospital. Most hospitals would be expected to have minimal to no available beds by this point in the outbreak. Suggested Moderator questions for group: Would another area of the hospital (e.g., Cafeteria or Physical Therapy Exercise Room) be used to handle overflow? Would you use an outdoor triage for those assessed not to be acutely ill? Instructions to Moderator: Final numbers for the outbreak should be provided here. Numbers should reflect tallies provided on previous slides. The total cases and fatalities are only those at your facility, not citywide numbers. Suggest using numbers that represent a > 40-50% surge for your hospital. Most hospitals would be expected to have minimal to no available beds by this point in the outbreak. Suggested Moderator questions for group: Would another area of the hospital (e.g., Cafeteria or Physical Therapy Exercise Room) be used to handle overflow? Would you use an outdoor triage for those assessed not to be acutely ill?

37. 37 Government Agency Responses The governor has requested resources from the Federal Government and the National Disaster Medical System has been activated [Local DOH] and [Office of Emergency Management] have set up points of distribution for dispensing antibiotics Based on the latest epidemiologic findings, [Local DOH], [Local Police Dept.] and FBI are conducting an environmental and forensic investigation at the presumed site of the attack [Local DOH] is maintaining a provider and public hotline, and continuing its active surveillance, regular health alerts and daily hospital conference calls [Local DOH] and [OEM] are working together with hospitals to address regional surge capacity needs There are frequent mayoral press briefings to address public concerns and minimize impact of the worried well on hospitals.

38. 38 Module ThreeGroup Discussion Instructions to Moderator: This is the opportunity to draw out groups/individuals who have maintained a low profile such as housekeeping, nutrition, social services, security, etc. Other important topics that may be discussed, if not already well-addressed during earlier modules, include: How will you provide mass care? How do you triage ambulatory, non-event related patients, and the “worried well” away from the ED? Where will you get the staff? Do you have rapid credentialing and privileging in place to recruit medical volunteers to your facility? How will you coordinate your efforts with the city, state and Federal response? Who do you call first? What steps should be taken to plan for the recovery phase? Instructions to Moderator: This is the opportunity to draw out groups/individuals who have maintained a low profile such as housekeeping, nutrition, social services, security, etc. Other important topics that may be discussed, if not already well-addressed during earlier modules, include: How will you provide mass care? How do you triage ambulatory, non-event related patients, and the “worried well” away from the ED? Where will you get the staff? Do you have rapid credentialing and privileging in place to recruit medical volunteers to your facility? How will you coordinate your efforts with the city, state and Federal response? Who do you call first? What steps should be taken to plan for the recovery phase?

39. 39 [Fourth of July] at [South Street Seaport] Some additional history… This is just an example of an event that could be used: The 28th annual July 4th Fireworks will be fired from a total of six barges; with three barges located at the traditional East River site. At approximately 8:00PM, a team of four United States Air Force A-10 Fighter Jets will do a flyover of the fireworks locations at the East River, wowing spectators with authentic military maneuvers. The fireworks will follow at 9:00pm. Meantime, in a nearby county a terrorist cell has prepared a blood broth medium in numerous 1-liter flasks using a small “apartment” laboratory. The flasks are inoculated using a master seed stock of Yersinia. Three devices of moderate sophistication are constructed. The terrorists take these 3 devices that can be triggered by either mechanical timer or by remote radio signal control. They load them into a small boat at night and move quickly up the East River to gain access to the firework site. They evenly space the devices out along a 50-meter distance. The mechanical timers are all activated simultaneously to detonate at 8:30pm the next night during the fighter jet flyover, and the backup radio control circuits are also armed. Local weather conditions at the time of the attack include a moderate inversion layer over the area with a 10 mph breeze gently blowing on this warm July evening. Within 6 minutes after the dissemination devices are triggered, the biological aerosol passes over the fireworks site and surrounding area and is now being inhaled by those watching the festivities. All infections occur within minutes of exposure to the aerosol and those individuals closest to the dissemination site receive the highest respiratory dose of plague organisms and will tend to have the first clinical presentation. There are no medical symptoms or other indications that a covert biological attack has taken place at this time.This is just an example of an event that could be used: The 28th annual July 4th Fireworks will be fired from a total of six barges; with three barges located at the traditional East River site. At approximately 8:00PM, a team of four United States Air Force A-10 Fighter Jets will do a flyover of the fireworks locations at the East River, wowing spectators with authentic military maneuvers. The fireworks will follow at 9:00pm. Meantime, in a nearby county a terrorist cell has prepared a blood broth medium in numerous 1-liter flasks using a small “apartment” laboratory. The flasks are inoculated using a master seed stock of Yersinia. Three devices of moderate sophistication are constructed. The terrorists take these 3 devices that can be triggered by either mechanical timer or by remote radio signal control. They load them into a small boat at night and move quickly up the East River to gain access to the firework site. They evenly space the devices out along a 50-meter distance. The mechanical timers are all activated simultaneously to detonate at 8:30pm the next night during the fighter jet flyover, and the backup radio control circuits are also armed. Local weather conditions at the time of the attack include a moderate inversion layer over the area with a 10 mph breeze gently blowing on this warm July evening. Within 6 minutes after the dissemination devices are triggered, the biological aerosol passes over the fireworks site and surrounding area and is now being inhaled by those watching the festivities. All infections occur within minutes of exposure to the aerosol and those individuals closest to the dissemination site receive the highest respiratory dose of plague organisms and will tend to have the first clinical presentation. There are no medical symptoms or other indications that a covert biological attack has taken place at this time.

40. 40 Hot Wash What have you learned during this tabletop exercise? What are the hospital’s Emergency Preparedness strengths? What are the weaknesses / gaps in 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 Instructions to Moderator: This is an open discussion that occurs immediately after the tabletop exercise and is conducted by the moderator. The objective of the “hot wash” is to review events or key decisions that took place during the exercise and to provide an opportunity for participants to describe any immediate lessons learned and to identify barriers/gaps in mounting an effective response. All participants are free to contribute and are encouraged to do so. Do not forget to distribute and collect the post exercise evaluation survey at the end of the hot wash. Instructions to Moderator: This is an open discussion that occurs immediately after the tabletop exercise and is conducted by the moderator. The objective of the “hot wash” is to review events or key decisions that took place during the exercise and to provide an opportunity for participants to describe any immediate lessons learned and to identify barriers/gaps in mounting an effective response. All participants are free to contribute and are encouraged to do so. Do not forget to distribute and collect the post exercise evaluation survey at the end of the hot wash.

41. 41 Thank you!