After-Action Report/Improvement Plan Template



Chaos and Confusion Regional Functional Exercise After-Action Report/Improvement PlanExercise Date: June 6, 2017Submitted June 28, 2017Most Recent Revision: August 15, 2017Clark County Combined Health DistrictThe After-Action Report/Improvement Plan (AAR/IP) aligns exercise objectives with preparedness doctrine to include the National Preparedness Goal and related frameworks and guidance. Specific to this report, the exercise objectives align with ASPR’s National Guidance for Healthcare Preparedness and the Hospital Preparedness Program Measures. Public Health Emergency Preparedness Capabilities are referenced as well. Exercise information required for preparedness reporting and trend analysis is included; additional sections have been added as a record upon which to build improvement. Record of Review and ChangeDateDescriptionBy Whom06/28/2017AAR/IP created and submitted to ODH C. ConoverC. Conover07/11/2017Added Appendix I to break down strengths/improvements according to the 6 critical areas according to The Joint Commission. C. Conover/ B. Dorsey07/13/2017Added Table of ContentsC. Conover08/15/2017Improvement Plan of this document was reviewed with CCCHD Administrative Team. C.ConoverTable of ContentsPageExercise/Incident/Event Overview1Executive Summary3Analysis of Health Care Preparedness Capabilities5HPP #10 Medical Surge8HPP #6 and PHEP #6 Information Sharing9PHEP #8 Medical Counter Measures12PHEP #9 Medical material Management and Distribution13PHEP #15 Volunteer Management14Conclusion15Appendix A: Improvement PlanA-1Appendix B: Exercise ParticipantsA-6Appendix C: Acronyms and Abbreviated TermsA-8Appendix D: Participant Feedback SummaryA-10Appendix E: Exercise Events SummaryA-15Appendix F: OPHCS Message ReportA-20Appendix G: ICS Form 205A-24Appendix H: Additional Example DocumentationA-27Appendix I: Strengths/Opportunities by Performance AreasA-37Exercise/Incident/Event OverviewExercise NameChaos and Confusion Regional Functional ExerciseExercise DatesJune 6, 2017ScopeThis is a functional exercise, planned for four hours during a one day period at multiple locations throughout West Central Ohio. Exercise play is limited to each county and the simulation cell.Mission Area(s)Protection, Mitigation, and Response.Public Health Preparedness CapabilitiesHPP Capability #10 - Medical SurgeHPP Capability #6 - Information SharingPHEP Capability #6 – Information SharingPHEP Capability #8 - Medical Counter MeasuresPHEP Capability #9 - Medical Material Management and DistributionPHEP Capability #15 – Volunteer ManagementObjectivesHPP #10 Medical Surge: Demonstrate the ability to provide adequate medical evaluation and care during a mass casualty incident that exceeds the limits of normal day-to-day operations. HPP #6 & PHEP #6 Information Sharing: Demonstrate the ability to share health related, response information, and situational awareness data among all partners. Demonstrate the ability to access and use both MARCS and OPHCS during a biological incident.PHEP #8 Medical Counter Measures: Demonstrate the capability to plan and prepare for providing countermeasures in support of prophylaxis to the identified population in accordance with public health guidelines and/or recommendations. PHEP #9 Medical Material Management and Distribution: Demonstrate the ability to request, maintain, and track SNS medical materials during a simulated biological incident. (EEGs will be used to address hospital request of SNS materials)PHEP #15 Volunteer Management: Demonstrate that processes are in place to request and activate volunteers to support the jurisdictions public health agency’s response during a simulated biological incident.Threat or HazardBiological Terrorist IncidentScenarioThe scenario for this exercise utilizes localized but severe impacts to the community resulting from a terrorist biological incident. Cascading events will exceed the capability for local agencies resources to respond to the incident. Coordination with state and federal partners will be needed to access assets to mitigate the effects of the terrorist biological incident. SponsorGreater Dayton Area Hospital Association with funding provided from the Ohio Department of Health through the Assistant Secretary for Preparedness and Response grant.Participating OrganizationsThe full list of participating agencies is listed in Appendix B. Point of ContactChristina Conover, Emergency Preparedness Coordinator (EPC), Clark County Combined Health District (CCCHD) 529 East Home Road, Springfield, OH 45503; 937-390-5600 ext. 279cconover@ Executive SummaryThe West Central Ohio Functional Exercise titled “Chaos and Confusion” was conducted on June 6, 2017. It focused on assessing a coordinated response to a biological terrorist incident on the WCO region. This After-Action Report (AAR) is used to document effectiveness and overall exercise performance. Exercises serve as “final accountability” of collective preparedness. The AAR/IP serves as a compendium of lessons learned, outlines recommended improvement plans, and provides the basis for planning future exercises. This AAR will contribute to improving preparedness for hospitals, public health, emergency management agencies (EMA) and other hospital coalition partners throughout the West Central Ohio (WCO) Region. Exercise Planning Team: CCCHD’s EPC was included on the planning team which was composed of representatives from hospitals, public health and public safety departments. The exercise planning team met approximately 6 times between December 2016 and June 2017. Objectives: Six objectives were selected for testing in addition to the annual Strategic National Stockpile (SNS) drills for the hospitals. Location: This Functional Exercise was played from various locations among the eight county region of West Central Ohio. In Clark County, there were 4 sites of play: Clark County Combined Health District office; hosting CCCHD players Mental Health Services of Champaign and Madison County (MHS) Clark County Emergency Management Agency (EMA) Vancrest of New Carlisle (Vancrest) Hospice of Miami Valley (HOMV) Oakwood Village (Oakwood)Rocking Horse Community Healthcare Center (RHCHCSpringfield Regional Medical Center (SRMC) This report will document the analysis of exercise results, identify strengths to be maintained, identify areas for further improvement, and support development of corrective actions.Major StrengthsThe major strengths identified during this exercise are as follows:(Region) Numerous hospitals were able to utilize triage areas outside of the main hospital structure.(Region and Clark) Regional Health Commissioners conference call ensured all health departments were following a similar response.(Region and Clark) The Ohio Department of Health maintains an antibiotic cache for disasters.(Clark) CCCHD has a Volunteer Management plan which demonstrates county and regional collaboration by including references to county and regional planning tools. Primary Areas for ImprovementThroughout the exercise, several opportunities for improvement in West Central Ohio’s ability to respond to the incident were identified. The primary areas for improvement are listed below.(Region and Clark) More robust information sharing procedures were needed by multiple partners across the individual counties as well as the region.(Region and Clark) A better understanding of the roles and responsibilities for response organizations concerning the SNS.(Region and Clark ) There is a need to increase the number of volunteers across the region.(Clark) There is a need for better understanding of Public Health’s role in medical surge needs within the community. (Clark) Closed POD program needs to be expanded. Overall, this exercise was a success. Participants had the opportunity to work with multiple partners in working to address the mitigation of a terrorist biological incident. It identified gaps or shortfalls in areas such as understanding of roles and communication shortcomings. By providing suggested corrective actions to be taken it will improve these capabilities within the region. Analysis of Healthcare Preparedness CapabilitiesAligning exercise objectives and healthcare preparedness 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 core capabilities, and performance ratings for each core capability as observed during the exercise from a regional perspective. ObjectivePublic Health Preparedness Capability/HPP CapabilityPerformed without Challenges (P)Performed with Some Challenges (S)Performed with Major Challenges (M)Unable to be Performed (U)Demonstrate the ability to provide adequate medical evaluation and care during a mass casualty incident that exceeds the limits of normal day-to-day operations. HPP #10 Medical SurgeHospitals(SRMC)HCPs (RHC)Inpatient Mental Health(MHS)Long Term Care(LTC):VancrestOakwoodHospice:HOMVDemonstrate the ability to share health related, response information, and situational awareness data among all partners.HPP Capability #6 - Information SharingPHEP Capability #6 – Information SharingHospitalsLHDs (CCCHD)LTCsHospicesHCPMHSEMADemonstrate the ability to access and use both MARCS and OPHCS during a biological incident.HPP Capability #6 - Information SharingPHEP Capability #6 – Information SharingHospitalsLHDsDemonstrate the capability to plan and prepare for providing countermeasures in support of prophylaxis to the identified population in accordance with public health guidelines and/or recommendations. PHEP Capability #8 - Medical Counter MeasuresLHDsDemonstrate the ability to request, maintain, and track SNS medical materials during a simulated biological incident.PHEP Capability #9 - Medical Material Management and DistributionHospitalsLHDsEMASome involvement:LTCsHCPHospiceMHSDemonstrate that processes are in place to request and activate volunteers to support the jurisdictions public health agency’s response during a simulated biological incident.PHEP #15 Volunteer ManagementHospitalsLHDRatings Definitions:Performed without Challenges (P): The targets and critical tasks associated with the healthcare preparedness 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 healthcare preparedness 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 healthcare preparedness 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 healthcare preparedness capability were not performed in a manner that achieved the objective(s).Table 1. Summary of Healthcare Preparedness Capability PerformanceThe following sections provide an overview of the performance related to each exercise objective and associated core capability, highlighting strengths and areas for improvement.Objective 1: Demonstrate the ability to provide adequate medical evaluation and care during a mass casualty incident that exceeds the limits of normal day-to-day operations.The strengths and areas for improvement for each HPP capability aligned to this objective are described in this section.HPP #10 Medical SurgeActivity 1: The Healthcare Coalition assists with the coordination of the healthcare organization response during incidents that require medical surge.Activity 2: Assist healthcare organizations with surge capacity and capability.Activity 3: Assess the nature and scope of the incident.Activity 4: Contingency plans discussed and/or activated.StrengthsThe partial capability level can be attributed to the following strengths:Strength 1: (Region) Multiple hospitals established triage areas outside of the hospital to assist with influx of patients and to limit what was hitting their Emergency Departments.Strength 2: (Clark) Health care organizations in Clark County demonstrated robust agency level responses from Healthcare Organizations playing in Clark County (i.e. shelter in place, lockdown, supply line alternatives, use of corporate assets.) Strength 3: (Clark) Hospice and Mental Health Services demonstrated plans to support other partner agencies by providing additional services as part of the community’s response due to multiple deaths. Areas for ImprovementThe following areas require improvement to achieve the full capability level:Area for Improvement 1: (Region) Delay with some hospitals dealing with in-patient units assessing potential discharges and transfer out of hospital. Reference: Local Hospital Response Plans and SOPs.Analysis: Multiple hospitals mentioned that a number of new staff we’re playing in a regional exercise for the first time. Thus experience on decision-making in this type of incident was limited as some sites. Options include more overlap between veteran staff and newcomers or additional training for newer staff before actual exercise. Area for Improvement 2: (Region) Kindred hospital was overlooked as a resource for freeing up inpatients from other hospitals. Reference: Local Hospital Response Plans and SOPs.Analysis: Kindred hospital was contacted for number of available beds but no one ever took advantage of the actual resource. Unless organizations make it a standard procedure to contact both facilities this will continue to be an unused resource. Kindred as well as Life-Care are facilities that would be available to accept in-patients from other hospitals to free up beds to deal with the medical surge incident. Both of these facilities should be added to internal SOPs to ensure the facility is contacted in a time of need. Additionally, it might be beneficial for GDAHA to also have this available within their SOPs.Area for Improvement 3: (Region and Clark) There is a need across the region for better information to partners about medical surge issues within the hospitals. Reference: Local Hospital Response Plans and SOPs; Public Health Preparedness Capabilities, CCCHD ERP.Analysis: Reporting of reportable diseases from hospitals to local health departments routinely happens on a day-to-day basis. Even though all LHDs should have access to OHTRAC now it does not mean it is monitored on a daily basis. During a large comparable incident it would be beneficial for all if the information was shared in a timely manner. It could be as simple as informing GDAHA and having them forward the information to either the LHD or regional PH coordinator. In Clark County, more users of OHTRAC must be identified and trained. Area for Improvement 4: (Clark) Need increased familiarity with the regional biological and epidemiology plans. Reference: Regional Biological and Epidemiological Plan.Analysis: Increased familiarity is needed to ensure that Clark County is able to cooperate well with the West Central Ohio Region by utilizing the assumptions and predetermined plans. Objective 2: 2a. Demonstrate the ability to share health related, response information, and situational awareness data among all partners. 2b. Demonstrate the ability to access and use both MARCS and OPHCS during a biological incident.The strengths and areas for improvement for each HPP/PHEP capabilities aligned to these objectives are described in this section.HPP #6 and PHEP #6 Information SharingActivity 1: Provide healthcare situational awareness that contributes to the incident common operating picture (HPP/PHEP).Activity 2: Develop, refine, and sustain redundant, interoperable communication systems (HPP).Activity 3: Identify stakeholders to be incorporated into information flow (PHEP).Activity 4: Exchange information to determine a common operating picture (PHEP)StrengthsThe partial capability level can be attributed to the following strengths:Strength 1: (Region) Regional health commissioner’s conference call was completed within the first hour ensuring all local health departments were operating from the same information. Strength 2: (Region and Clark) Redundant interoperability using MARCS radios was established early between hospitals and local health departments during the exercise.Strength 3: (Region and Clark) Health Alert Network (HAN)/ OPHCS was used to get key incident response information to partners.Strength 4: (Region) Numerous locations identified that IC within HICS/DOC provided situational update on hourly basis.Strength 5: (Clark) Good success and evidence of use of ICS forms, particularly for communicating general messages and closing circle for resolution. Forms utilized included ICS 214, 213 RR, 213, 205, 206, etc. See Attachments. Strength 6: (Clark) Partner Healthcare Organizations communicated frequently with Communicable disease unit regarding individual case information. This is evidenced by documented 213 and 214 forms created during the exercise. This strength is separate from the gap noted in areas for improvement, which speaks to situational awareness. Strength 7: (Clark) EMA was able to assist with information sharing to partners particularly in acting as a liaison with Law Enforcement. Strength 8: (Clark) In review of exercise documentation, there was evidence of research and outreach regarding safety of responders both internal to CCCHD and external such as first responders. This is in line with the Public Health Preparedness capabilities. In example, the type of PPE and disinfection processes for tularemia were available due to research to establish a known profile of the biological threat. Areas for ImprovementThe following areas require improvement to achieve the full capability level:Area for Improvement 1: (Region and Clark) It was observed at multiple locations that information was not being readily shared with all partners dealing with the response. Reference: Local Communications Plans and SOPs. Analysis: Hospitals, LHDs, and other participating organizations stated that they could have shared more information and wanted to receive more information. Contact lists should be updated and new organizations added to ensure partners are updated on key situational information. There will be times during an actual incident where communication will be limited. Redundancies put in place now will ensure the possibility of open communications lines during an actual disaster. Additionally, in Clark County, more robust Information Sharing procedures must be put into place. The barrier was not communication systems, rather a general need to increase the priority of information sharing and engaging partners proactively. Area for Improvement 2: (Region and Clark) There was confusion on messaging concerning SNS assets and the cache maintained by ODH. Reference: Local Communications Plans and SOPs. Analysis: A memo generated by a participating organization during the exercise stated that the SNS would be here in 3 hours when it was actually referring to the ODH cache. The SNS assets would arrive roughly between 18 to 24 hours. The state cache could arrive in roughly 3 hours. Additional information needs to be gathered concerning the State cache. Area for Improvement 3: (Region) There were multiple sites complaining of communication issues where phone lines did not roll over and radio use was causing computer issues.Reference: Local Communications Plans and SOPs. Analysis: A number of sites have recently added new phone lines that are intermixed with older systems. Due to this some phones which were set-up to rollover would never ring on the receiving end. In addition some sites had radios that were overriding and shutting down computers. Organizations should review their communication assets to ensure there is happy medium of the new and old merging together instead of canceling out each other. Area for Improvement 4: (Clark) Information did not always flow well within the public health DOC. Reference: Local Public Health ERPs and SOPs. Analysis: Struggled to find battle rhythm during exercise to allow for round the room updates. Additionally, there is some apprehension about roles. The EPC received many requests from players for more specific direction for role in the DOC. Job Action sheets need to be developed with more detail. Area for Improvement 5: (Clark) Animal and Agriculture resources need to be available for consult; partners expect this kind of information from public health. Reference: Local Public Health ERPs and SOPs. Analysis: Animal welfare is an important aspect of a community’s response and in the absence of another lead agency, public health will be expected to respond in the matters of animal health in light of threat. Objective 3: Demonstrate the capability to plan and prepare for providing countermeasures in support of prophylaxis to the identified population in accordance with public health guidelines and/or recommendations.The strengths and areas for improvement for each PHEP capability aligned to this objective are described in this section.PHEP Capability #8 - Medical Counter Measures (MCM)Task 1: Engage subject matter experts (e.g., epidemiology, laboratory) and local partners, to determine what medical countermeasures are best suited for the incident.Task 2: Engage subject matter experts (e.g., epidemiology, laboratory) and local partners, to determine what medical countermeasures are available for the incident.Task 3: During incident, engage private sector, local, state, regional, and federal partners, as appropriate to the incident, to identify and fill required response roles.Task 4: Have or have access to a reporting system.StrengthsThe partial capability level can be attributed to the following strengths:Strength 1: (Region and Clark) The majority of health departments quickly accessed the states standing orders for recommendations. Strength 2: (Region and Clark) It was identified that ODH maintained a cache of antibiotics that could be requested by locals before the SNS was requested. Strength 3: (Region and Clark) Epidemiologists were readily available to assist and gather necessary data.Strength 4: (Clark) Partners very interested in Closed POD and began to create dispensing plans for staff and clients. This included agencies that had residential clients as well as agencies with clients in the community such as Hospice. Areas for ImprovementThe following areas require improvement to achieve the full capability level:Area for Improvement 1: (Region and Clark) Understanding of what the ODH cache is and what it is available for. Reference: Local SNS and Mass Prophylaxis PlansAnalysis: While ODH does maintain a cache of antibiotics the vast majority of hospitals and local health departments were unaware of its existence, more information needs to be gathered on this resource. Specifically, who is it available too? How much is available?Area for Improvement 2: (Region and Clark) Requests to pharmacies as dispensing sites and regional Points of Dispensing need much more review. Reference: Local SNS and Mass Prophylaxis PlansAnalysis: On a national level there has been the initial discussions involving pharmacies dispensing SNS antibiotics as well as the possibility of regional POD sites. Both of these options need much research and review before contemplating their use. Areas for Improvement 3: (Clark) Closed POD agreements need to be formalized pre-event. Reference: Local SNS and Mass Dispensing PlansAnalysis: There is great interest from local health care coalition partners and CCCHD needs to be more responsive in a timely manner to put these agreements in place. Areas for Improvement 4: (Clark) There is a need for more familiarity with the Strategic National Stockpile assets, including what medications should be requested for prophylaxis. Reference: Local SNS and Mass Dispensing Plans, ODH Standing Orders. Analysis: Requesting supplies became a challenge when public health was attempting to place an order to cover both treatment and prophylaxis. There may have been some confusion regarding treatment (with initial cases) and then switching to prophylaxis. Additionally, the forms for requesting MCM were outdated in the Clark County plan. Objective 4: Demonstrate the ability to request, maintain, and track SNS medical materials during a simulated biological incident. (EEG will be used to address hospital request of SNS materials).The strengths and areas for improvement for each HPP/PHEP capabilities aligned to this objective are described in this section.PHEP Capability #9 - Medical Material Management and DistributionActivity 1: Direct and activate medical materiel management and distribution.Activity 2: Acquire medical materiel.Activity 3: Hospital Material Management Planning.StrengthsThe partial capability level can be attributed to the following strengths:Strength 1: (Region and Clark) All local health departments had solid Strategic National Stockpile (SNS) plans in place and were readily available and used during the exercise. Strength 2: (Region) There was collaboration between some hospitals and local health departments during the SNS requesting process. Areas for ImprovementThe following areas require improvement to achieve the full capability level:Area for Improvement 1: (Region and Clark) Details involved with the requesting process for the SNS. Reference: Local SNS and Mass Prophylaxis PlansAnalysis: While all locations understood that hospitals and health departments must request the SNS through their county EMA there was a definite need for more specific training for hospitals, health departments and EMAs. Area for Improvement 2: (Region and Clark) Need for establishing additional closed PODs. Reference: Local SNS and Mass Prophylaxis PlansAnalysis: Numerous health departments acknowledged that there was a definite need for identifying and establishing additional closed PODs. These would be in place to reduce the number of individuals showing up at general PODs throughout the individual counties; thus lessening the burden on LHDs and improving the likelihood of a larger number of individuals receiving their prophylaxis.Area for Improvement 3: (Clark) EMA could be utilized more to obtain assets needed to set up PODS or receive material. Reference: Local SNS and Mass Prophylaxis PlansAnalysis: Better utilizing EMA in this function would free up public health personnel for other necessary tasks. Objective 5: Demonstrate that processes are in place to request and activate volunteers to support the jurisdictions public health agency’s response during a simulated biological incident.The strengths and areas for improvement for each PHEP capability aligned to this objective are described in this section.PHEP Capability #15 – Volunteer Management Task 1: At the time of an incident, identify the desired skills and quantity of volunteers needed for the incident from the pre-incident volunteer registration. Task 2: At the time of an incident, contact pre-incident registered volunteers using multiple modes of communication. Task 3: Determine staffing needs for POD operations. StrengthsThe full capability level can be attributed to the following strengths:Strength 1: (Region and Clark) Demonstrated that processes were in place for contacting and requesting volunteer resources for assistance during need. In Clark County, the Volunteer Reception Center (VRC) was requested and mentioned in the Volunteer Management Plan. Strength 2: (Region) Hospitals utilized medical students, volunteers and extra staff to support the response. Strength 3: (Region and Clark) Planned for the opening of a volunteer reception center to ensure additional volunteers would be available when needed. Areas for ImprovementThe following areas offer improvement to the full capability level already addressed:Area for Improvement 1: (Region and Clark) Increase number of volunteers available. Reference: Local Plans and SOPsAnalysis: Multiple locations identified the need to increase the number of volunteers within their organizations to provide support during similar incidents. Look at possible volunteer recruiting opportunities as an option for increasing numbers to pull from during actual incidents. Area for Improvement 2: (Region and Clark) Identify backups for primary volunteer coordinators.Reference: Local Plans and SOPsAnalysis: Some locations noted that they did not have a backup to their primary volunteer coordinator and were unable delegate and dispatch volunteers where needed. Identifying a backup will ensure a smooth transition if the primary is unavailable for any reason.Area for Improvement 3: (Clark) Need to exercise VRC once moreReference: Local Plans and SOPsAnalysis: United Way has had personnel turnover and exercising the VRC would be beneficial. ConclusionThe Chaos and Confusion FE successfully met the established objectives and provided an opportunity for those with a role in response to a biological terrorist incident to apply the actions and resources that would be needed to work collaboratively and share resources and information with local, regional, and State partners. The lessons learned from the exercise will be used to improve planning, coordination, and response to future incidents.The internal and external coordination that occurred during the exercise confirmed that the stakeholders involved in the exercise are committed to ongoing testing of plans, policies, procedures, and capabilities to assure an effective and coordinated response to any type of incident.An Improvement Plan (IP) has been included as an appendix to this document. To address the gaps that have been identified, stakeholders should immediately begin taking steps to collaborate on a plan to commence the activities necessary to accomplish recommended improvements, and to continually measure the progress made. Appendix A: Improvement PlanThis IP has been developed specifically for Clark County and CCCHD as a result of Chaos and Confusion conducted on 06/06/2017. PHEP CapabilityIssue/Area for ImprovementCorrective ActionCapability ElementPrimary Responsible OrganizationOrganization POCStart DateCompletion DateHPP #10 Medical Surge: 1. There is a need across the region for better information to partners about medical surge issues within the hospitals.Increase PH users by 2 persons (total 4) and increase familiarity with OHTRAC TrainingCCCHDEPC07/01/201712/01/2017PH to better understand how SRMC uses OHTRACPlanningCCCHD/SRMCEPC07/01/201712/01/CHD needs increased familiarity with Regional Biological and epidemiology plansProvide review of Epi plans (local and regional) with Admin Team/PIO and CD teamsTrainingCCCHDEPI07/01/201712/31/2017Provide review of Biological plan and how it intersects with local ERP. Audience Admin/PIO and CDTraining CCCHDEPC01/201803/2018PHEP CapabilityIssue/Area for ImprovementCorrective ActionCapability ElementPrimary Responsible OrganizationOrganization POCStart DateCompletion DateHPP# 6 PHEP # 6 Information Sharing1. Need more robust information sharing plans.Create and revise procedures PlanningCCCHDEPC07/01/201709/01/2017Share with CCCHD StaffTrainingCCCHDEPC09/01/201701/15/2018Create a liaison job description within ICS that is specifically responsible for sharing information with partnersPlanning CCCHDEPC07/01/201703/01/20182. Struggled to establish battle rhythmRevise ERP to highlight battle rhythm for information sharing in DOCPlanningCCCHDEPC07/01/201703/01/20183. Animal and Agriculture resources need to be available for consult. Establish SME resources and include in ERP as a referencePlanning CCCHDEnvironmental Division Personnel07/01/201707/01/2018[Continue adding capabilities and related information as relevant.]PHEP CapabilityIssue/Area for ImprovementCorrective ActionCapability ElementPrimary Responsible OrganizationOrganization POCStart DateCompletion DatePHEP # 8 Medical Countermeasures1.Learn more information regarding ODH cache and SNS assets.Attend IMATS TrainingTrainingCCCHDEPC11/201712/2017Update Mass dispensing plan with new forms for MCMPlanningCCCHD EPC07/01/201711/01/2017Attend CDC training for SNS.TrainingCCCHDNursing Supervisor or designee07/01/201707/01/20182. Increase number of closed PODsRequest help from Nursing division to assist in recruiting and formalizing agreements for closed PODSOrganizationCCCHDEPC/Nursing Division and Health Care Partners07/01/201707/01/2018Attend CDC training for SNS.TrainingCCCHDNursing Supervisor or designee07/01/201707/01/2018[Continue adding capabilities and related information as relevant.]PHEP CapabilityIssue/Area for ImprovementCorrective ActionCapability ElementPrimary Responsible OrganizationOrganization POCStart DateCompletion DatePHEP #9 Medical Material Management and DistributionNeed to increase understanding of requesting process for SNS or mass prophyAttend IMATS TrainingTrainingCCCHDEPC11/201712/2017Tabletop exercise with CCCHD groupExerciseCCCHDEPC07/201708/2018Regional exercise in November 2017ExerciseCCCHDEPC07/201712/01/2017Yearly training with closed POD partnersTrainingCCCHDEPC07/201708/2018[Continue adding capabilities and related information as relevant.]PHEP CapabilityIssue/Area for ImprovementCorrective ActionCapability ElementPrimary Responsible OrganizationOrganization POCStart DateCompletion DatePHEP #15Increase # of volunteersRecruit for MRCOrganizationCCCHDMRC coordinator07/201707/2018Increase comfort with VRC conceptsExercise VRCExerciseCCCHDEMA07/201707/2018[Continue adding capabilities and related information as relevant.]Appendix B: Exercise ParticipantsAgencies within Clark County who participated in the exercise are highlighted in yellow.Participating OrganizationsCoalition Member Type# in Coalition# Participating% ParticipationState & Local GovernmentOhio Department of Health11100%Local Health Departments8 (Regional HCC)8100%Champaign Health DistrictClark County Combined Health DistrictDarke County General Health DistrictGreene County Public HealthMiami County Public HealthPublic Health – Dayton & Montgomery CountyPreble County Public HealthSidney-Shelby County Health DepartmentEmergency Management Agencies8 (Regional HCC)788%Champaign County EMAClark County EMAGreene County EMAMiami County EMAMontgomery County Office of Emergency ManagementPreble County EMAShelby County EMAMental Health Services1 (Clark HCC)1100%Mental Health Services for Clark and Madison CountyFederally Qualified Health Center2 (Clark HCC)150%Rocking Horse Community Health CenterBoard of Developmental Disability1 (Clark HCC)00%Shelby County Board of DDNon-government Coalition Members and PartnersHospitals2 (Clark HCC)150%Community Mercy Health PartnersDayton Children'sGood Samaritan HospitalGrandviewGreene MemorialJoint Township HospitalKindred HospitalMiami Valley HospitalSoin Medical CenterSpringfield Regional Medical CenterUpper Valley Medical CenterWayne HospitalWilson HealthLong Term Care Facilities14 (Clark HCC)214%CRSIOakwood VillageVancrest of EatonVancrest of New CarlisleVancrest of UrbanaHospiceUnsure Hospice of Miami CountyHospice of the Miami ValleyOhio’s Hospice of DaytonAdditional Information/CommentsOhio EMA Representative was located at the CCCHD exercise location as support and observer. Cedarville University representative was located at the CCCHD exercise location as an observer. Appendix C: Acronyms and Abbreviated TermsAcronymStands for:NotesAAR/IPAfter Action Report / Improvement PlanCCCHDClark County Combined Health DistrictCDCommunicable DiseaseDOCDepartmental Operations CenterEMAEmergency Management AgencyEMSEmergency Medical ServicesEOCEmergency Operations CenterEPCEmergency Preparedness CoordinatorEPIEpidemiologistERPEmergency Response PlanHICSHospital Incident Command SystemHCPHealth Care ProviderHOMVHospice of Miami ValleyICIncident CommanderICSIncident Command SystemILIInfluenza Like IllnessLELaw EnforcementLTCLong Term CareMARCSMulti Agency Radio Communication SystemMHSMental Health Services of Clark and MadisonMCMMedical Countermeasuresi.e. antibiotics for exposure to tularemiaNOSNot Otherwise SpecifiedOakwoodOakwood VillageODHOhio Department of HealthOEMAOhio Emergency Management AgencyOPHCSOhio Public Health Communication SystemSends messages by email, text or phone callPDPolice DepartmentAs in “Spfld PD” or Springfield PDPH Public HealthPIOPublic Information OfficerPODPoint of DispensingqeveryRHCHCRocking Horse Community Health CenterS/SSigns and symptomsSNSStrategic National StockpileSOPStandard Operating ProcedureSRMCSpringfield Regional Medical CenterSxSymptomsVancrestVancrest of New CarlisleVRCVolunteer Receptions CenterAppendix D: Participant Feedback SummaryParticipant Feedback Form from June 6 Hotwash@ Clark County Combined Health District locationThank you for participating in this exercise. Your observations, comments, and input are greatly appreciated, and provide invaluable insight that will better prepare our region against threats and hazards. Any comments provided will be treated in a sensitive manner and all personal information will remain confidential. Please keep comments concise, specific, and constructive.Part I: General InformationPlease enter your responses in the form field or check box after the appropriate selection.Name: Clark County Group Feedback (5 agencies)Agency / Organization Affiliation: Clark County Combined Health District; Vancrest of New Carlisle, Mental Health Services of Clark/Madison, Clark EMA, Hospice of Miami ValleyPosition Title: submitted by C. Conover- input from multiple participantsYears of Experience in Present Position: Number of Exercises Previously Participated in: FORMCHECKBOX 0 FORMCHECKBOX 1-5 X 5-10 FORMCHECKBOX 15+Exercise Role: FORMCHECKBOX Player FORMCHECKBOX Facilitator/Controller FORMCHECKBOX Observer FORMCHECKBOX EvaluatorLocation during Exercise: Clark County Combined Health DistrictPart II: Exercise DesignPlease rate, on a scale of 1 to 5, your overall assessment of the exercise relative to the statements provided, with 1 indicating strong disagreement and 5 indicating strong agreement.Assessment FactorStronglyDisagreeStrongly AgreePre-exercise briefings were informative and provided the necessary information for my role in the exercise.12345The exercise scenario was plausible and realistic.12345Exercise participants included the right people in terms of level and mix of disciplines. 12345Participants were actively involved in the exercise.12345Exercise participation was appropriate for someone in my field with my level of experience/training.12345The exercise increased my understanding about and familiarity with the capabilities and resources of other participating organizations.12345The exercise provided the opportunity to address significant decisions in support of critical mission areas.12345After this exercise, I am better prepared to deal with the capabilities and hazards addressed.12345Part III: Participant FeedbackI observed the following strengths/improvement areas during this exercise (please select the capability and applicable element related to the strength/improvement areas):Strengths/Improvement AreasCore CapabilityElement Improvement Area: Could public health have role in helping support Crisis Intervention response in this scenario. In house inventory of trained staff more visibleEncourage public health familiarity with Regional Biological Response Plan, Epi Response PlanStrengths: Healthcare Partners playing at CCCHD (Mental Health Services, Hospice of Miami Valley, Vancrest) have good grasp on their internal responses. Evidence/demonstration of robust plans to lockdown, shelter in place, supply line alternatives, use of corporate assets, etc. Medical SurgePlanningOrganizationEquipmentTrainingExerciseX FORMCHECKBOX FORMCHECKBOX X FORMCHECKBOX Improvement Area: Partners (especially healthcare partners) need more information sharing from the health district: situation updates, etc. Consider: in the public health structure, do we need to plan a specific unit under operations for information sharing? Need more robust information sharing written procedures at CCCHDNeed way to quickly formulate FAQ’s and consistent message, based on inquiries received from the public; Communicable Disease will quickly get overwhelmed answering calls. So need to engage other staffConsider: is there a way for CCCHD to post regular updates so partners could go in and get those updates on a regular basis during an incident and response? Or is there an existing structure upon which to share information? Partners want clearer guidance pushed to them on environmental involvement such as clean up, weather impact re: transmission and exposureStrength: Use of Facebook/Twitter handlesInformation SharingPlanningOrganizationEquipmentTrainingExerciseX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Improvement Areas: Need broader understanding and knowledge base of SNS volume, characteristics (public health)More closed PODs need to be organized and agreements completed in advance.Medical Counter MeasuresPlanningOrganizationEquipmentTrainingExercise FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX X FORMCHECKBOX Improvement Areas: Need broader understanding and knowledge base of SNS volume, characteristics and agency roles in receiving stockpile (public health and healthcare partners including EMA)Medical Material Management and DistributionPlanningOrganizationEquipmentTrainingExercise FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX X FORMCHECKBOX Improvement Area: Could public health have role in helping support Crisis Intervention response in this scenario. In house inventory of trained staff more visibleAlter Volunteer Management Plan with some details about requesting the Volunteer Reception Center (VRC)Volunteer ManagementPlanningOrganizationEquipmentTrainingExerciseX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Improvement Area: In the public health DOC: we need Job Action SheetsDefine Scope of Public Health Safety Officer; does it include info sharing/recommendations to health care partners?Routing info within the DOC is still a need for improvement; need routine “round the room” updatesAnimal and Agriculture resources need to be available for consult; Partners want this kind of information available from public healthOther(Public Health: Emergency Operations Coordination)PlanningOrganizationEquipmentTrainingExerciseX FORMCHECKBOX FORMCHECKBOX X FORMCHECKBOX Which exercise materials were most useful? Please identify any additional materials or resources that would be useful.No group conversation on this, but player prep materials well received. In addition, the printed out injects were very nice. Please provide any recommendations on how this exercise or future exercises could be improved or enhanced. Simcell: is there an alternate way to go about this? Multiple failed attempts to call by many different units/agencies in the room; phone lines being busy may be realistic but if this happened, we would then find an alternate route to communicate with our partners, if it meant getting in the car and driving there. What if we engaged local partners to be the Simcell? They don’t have to commit to playing as an agency, just commit to pick up the phone for 4 hours and provide a response that they would likely give (i.e. law enforcement) Note from C. Conover: Phonebook and registration: agencies were not aware that they needed to “register” again, after they thought they had “signed up” through GDAHA or me. I could not tell in real time which agencies had registered or not, so I thought all was well until last day before exercise. Larry was great to take my phone call despite many other things he had to juggle day before but as it is info and numbers still were not correct on final copy of phone book. Also, some agencies registered as controllers and not players. I am seriously not trying to say that this challenge is any one person’s responsibility, because it is all of ours; so what could I do to help? Additional cumulative participant feedback is gathered in a file at Clark County Combined Health District and is available upon request. Appendix E: Exercise Events SummaryIn formulating its analysis, the evaluation team has assembled a timeline of key exercise events. This section summarizes what happened during the exercise in a timeline table format. Focus of this section is on what inputs were presented to the players and what actions the players took during the exercise. Successful development of this section is aided by the design, development, and planning actions of the exercise design team. DateTimeScenarioMHSRHCHCOakwoodSRMCEMAVancrestHOMVCCCHDOtherEvent/Action 06/05/17XFBI Fire Line received discussing increased threat of terrorist activity; Increased evidence of security at public events; WPAFB Security Level Bravo XSuspect mosquito spraying is the mechanism used to disperse an agent. Individuals of suspected terror events apprehended; film of them consulting with specific individuals who are not apprehended. Description availableXIncreased surveillance through healthcare and public health systems requestedxCase counts of ill persons in Jacksonville, Norfolk, Watertown available; CDC providing a case definition, case definition shared with providers. Health care providers and all agencies fielding calls; residential facilities are seeing supply shortages threatened. xSNS being requested in other states. Tularemia confirmed per lab tests. Strain is virulent, has been weaponized; does not have the same characteristics as naturally occurring tularemiaxSimulated shared FBI info with first responders and other partners through email networksxSet up CCCHD DOC 06/06/170800XxReports of increase in persons with local Influenza Like Illness (ILI); ODH lab and OPHCS info received0808XxOakwood contacted CCCHD: 8 people with delirium, UR, fever, 2 more suspect; no swabs0809XXRHC Contacted HD: Tularemia info needed; assured Health Alert would be getting to them0810xUsed Emergency call list to notify staff not to visit Oakwood due to mx with sx. Make sure all staff has PPE; if not, go to office and obtain PPE. 0810xWPAFB traffic backed up, threat level Charlie and detailed ID checks, avoid area if possible0810xNotified staff of office closures in Xenia and other satellite clinics0809XXCall to Oakwood: 8 in need of PCR lab; defined suspect case; confirmed no swabs; need to order0810xReviewed info on Rabbit fever, texted info to all staff0820xAll managers notified of update and advised to stay tune to local news station. Notify all patients in areas of situation. Follow q every 1-2 hours. Managers to use text with updates to staff. 0821xxOakwood has upset family members; requesting crisis team from MHS. MHS will re-evaluate after LE engaged to take care of active/suspicious mosquito spraying around Oakwood0827XXMHS staff member ill from festival (replaced ill staff member on duty): call to find out more info regarding festival; called to SRMC to see if any positive tularemia0827 xHealth Alert released from Comm. Disease Unit; audience: HCP, Urgent Cares, clinics, hospitals0830xMedia reporting situation and threat as told by Reliable Anonymous Secret Source (fabricated for exercise- “Anonymous”)0830xXFrom Dayton Children’s: 1 Clark patient in ED: 15 y.o. male s/s of tularemia; call to DCMC: child serum positive for tularemia no demographics, all sx of Tularemia as probably cause. Entered case in ODRS. 0830xInfo out to all MHS staff; implement screeing procedures for vitals; contact SRMC, stop visitation on inpatient, modified precautions. 0835xList and patients experiencing s/s and report to HD or EMA. Notify all about protocol; f/up on needs (priority list). Updates to staff0838xXXMental Health and Oakwood contacted CCCHD: There is mosquito spray happening: should they cover (AC) units? who sprayed? PCR tests done x 8; increased sx0840xxVancrest called CCCHD: requested pharmacy and equipment from corporate headquarters; nothing available; staff person ill and isolated; air off/windows closed; self-quarantined; PCR advised 0850xCalling local pharmacies in area to determine antibiotics and supplies. 0850xxMore info on sick staff member from Vancrest; attended soccer tournament. 0850xContacting in house pharmacy for tx of tularemia; some short supply available from in house pharmacy. 0857XxHospice reported to CCCHD: staff member with HA/ fever; attended festival past weekend, sending home. Strawberry festival : advised testing0858xMental Health Services contacting HD with questions: client reporting suspicious activity; no symptoms. Discussed S/S of tulermia, not person to person, if sx send to hospital. 0900xUnable to get ahold of DME supplier0900xxOakwood: 8 swabs positive for tularemia, maintenance sprayed for mosquitos; running out of meds. Oakwood had received some meds from Kroger, but need more. 0900xxCall to SRMC for cache and amounts; SRMC has 1 positive for Tularemia and 41 with sx, 0900xxCall to ODH and advised of meds for Tularemia, advised to go through EMA for pushpack. Discussed RMRS and regional supply SRMC ordering but needed form. CCCHD ordering through SRMC0901xxSafety officer contacting LE about reported threat of tularemia; discussed PPE for law enforcement and ways to keep LE safe. Requested ongoing communication about situation0902xxSRMC and CCCHD discussed symptoms and treatment.0907 xxLE contacting CCCHD requesting prophylaxis for officers. None at this time. watch for fever/exposure0910xxSpoke with Maj. Chris Clark @CCSO: if it is credible terrorist activity and have been alerted by FBI, it is unsafe to approach. (HD trying to determine proper PPE) Deadly force can be used. 0910xUpdates to staff with news info re: suspects; texted pictures of suspected vehicle0910xCrisis hotline established for support (Mental Health?)0915xCalled ODH for info re: a crisis line; ODH has set up a line #614-555-1234; info relayed to receptionist and PIO0915Xalled RMRS for antibiotics0916XAll agencies experience “sick” staff members…those with last names beginning with A, B, C0920xStaffing issues: changed assignments to cover services0920xSurge: notify all staff on one call system that we will have antibiotics available for them and their families0925x5 nurses/5 SW advised to go to Soin MC0925xPublic Health Objectives: Engage Law Enforcement to stop spraying.Determine nature and extent of illness.Determine local stockpile regionally 0927xDetermined air purifying respirator to be worn with level C PPE. Attempt to contact LE- unable; called EMA to ask for help in notifying LE. 0930xxReceived call from HD: how do they request SNS? I advised there is a form. Sent. 0930xxOakwood Independent living residents with animals concerned called to discuss exposure usually limited to certain animals0932xxIn response to a request, MHS notified Oakwood Village: MHS cannot physically send crisis team to their location. We will set up a team in MHS board room and receive calls and provide assistance. 0935xContacted HD regarding suspicious activity: recommend call LE; calling LE0940xCall med lab to do PCR testing on 1 staff, 3 clients0944xAdditional Public Health Objectives:Set up open and closed PODSRequest SNS0945xxxOakwood needs doxy; noted fatality; 63 residents with s/s and 17 staff ill. Need meds, discussed pushpack; contacted Hospice to be prepared to assist0946xxMHS Visitor with sx sent to ED; visitors now restricted; reviewed not s/s 0950xxContacted both GCPH and CCCHD for closed POD0950xArrangement for contacting staffing agencies if needed0950xxVisitor with sx, sent away; reviewed not person to person asked to refer those with sx for testing.0955xxConfirmed arrangements as a Closed POD0956xxSRMC: 1 confirmed case; wants to coordinate with HD to get message out; pts to ED with sx. Call to SRMC- confirmed #s seen for s/s of Tularemia; askedto call with # of confirmed or positive PCR tests0958xSNS requestedxMHS has food: 7 day supply for inpatient (MRE’s); Medicine for Inpatient: Madison Avenue will work with MHS1000xText to staff to update antibiotics (prophy) for staff and PTs1000xDropsite confirmed on OPOD1000xRequesting staff surge in the Comm Disease Unit (request to planning1000xxLocal school: 3 children sick, sent home ILI; discussed s/s and advised no shutdown1002xShared license plate info with LE1008xRHCHC Reporting Class A: transported 4 to SRMC and 2 to DCMC; 18 tx but not transported; several reported park attendance and 1 strawberry festival1009xxHospice: pt with s/s, attended park over weekend; requeted PCR tested; notified Hospice of other deaths1010xSafety officer Asked about tularemia in water: lakes, ponds, streams and if deactivated by sunlight1010xxFire asking for Prophylaxis- responded working on it1010xCall to ODH for countermeasures/PEP for first responders and critical infrastructure; advised IC to decide critical infrastructure but can prophy/PEP1015xAdvised staff that exposure widespread; all to wear PPE or at least masks1015xInfo to local parks upon their inquiry. Using EMA as liaison to local parks, due to difficulty contacting parks directly1015xSet up child care for staff with small children who can come to work; used 1 call system to communicate 1025xFollow up with HD re: closed PODS ending1025xFielding questions about white powder in car rental companyxMHS notified staff regarding antibiotics to be distributed to staff members and family as a Closed POD; working on antibiotic distribution plan; Cipro is OK for pregnant staff members1025xxEMA contacted to request VRC1030xOrdering/Requesting equipment for unloading push pack1040xEMA sent 12 hr. push pack to OEMA1044xxVRC Request form provided to CCCHD from EMA1052xxReceived information from ODH that SNS would arrive in Clark in 2.5 hours; info to HD1100xContinue fielding questions from suspected exposed persons1100xOrdering refrigerated trucks/units for deceased; requiring mx calls1105xxDiscussion with SCAT: Buses and drivers for PODS; but requesting treatment for drivers1110xxContacted United Way for VRC; will open at 10 PM1110xMedia noting scattered reports that people are crowding into stores, looting/fighting.1115xEvent planner: asking should she cancel outside event, what is exposure from contaminated objects? Discussed bleach cleaning1122xPlanning for closed POD initially1130xShelter in place due to suspicious activity1130Received request for additional cold storage; UHF radios to HD1142 xSecured 4 refer trailers for dead body storageNOSxxCommunicated with SRMC over MARCSSocial media injects throughout Appendix F: OPHCS Message ReportThe Ohio Public Health Communication System (OPHCS) must be integrated into all functional and full scale exercises conducted before during and after and exercise. Uses can include notification of exercise, situational awareness, and end of exercise. Included here is the OPHCS Message Report. 1819275-5097780CCCHDVancrestMental HealthOakwoodRocking HorseClark EMASRMCRocking HorseHospice of MV00CCCHDVancrestMental HealthOakwoodRocking HorseClark EMASRMCRocking HorseHospice of MVAppendix G: ICS FORM 205This ICS 205 form documents the incident radio communication plan utilized during the exercise.1. Incident Name:Tularemia Exerise (Chaos and Confusion) 2. Date/Time Prepared:Date: 6/6/2017Time: 10003. Operational Period: Date From: 6/6/2017Date To: 6/6/2017Time From: 0800Time To: 12004. Basic Radio Channel Use:Zone Grp.Ch #FunctionChannel Name/Trunked Radio System TalkgroupAssignmentRX Freq N or WRX Tone/NACTX Freq N or WTX Tone/NACMode(A, D, or M)Remarks11Monitor for Situational AwarenessXClarkR. Holbrook Received Test message from ODH2Monitor for Situational AwarenessXLDH-WCENJodi Wood 21Monitor for Situational AwarenessXLDH- WCENJan Walker 5. Special Instructions: 6. Prepared by (Communications Unit Leader): Name: R. HolbrookSignature: Signed by Rick HolbrookICS 205 IAP Page Date/Time: 6/6/2017 12:00 AMAppendix H: Additional example Documentation Created During Exercise 7210425809625 Appendix I: Strengths and Opportunities by Performance AreasMany strengths and improvements can be categorized in more than one area.Strength = Cumulative Strength Noted from Exercise Improvement = Cumulative Area for Improvement Noted from ExerciseS = Strength identified by Individual Feedback; I = Area for Improvement identified by Individual FeedbackNotification(Strength): (Region) multiple hospitals established triage areas outside of the hospital to assist with influx of patients and to limit what was hitting their Emergency Departments.(Strength): (Region and Clark) Epidemiologists were readily available to assist and gather necessary data.(Improvement): (Clark) Closed POD agreements need to be formalized pre-event.(Strength): (Region) There was collaboration between some hospitals and local health departments during the SNS requesting process.(I) Need better info sharing; partners need more notification from CDC, local public health, etc. (S) OPHCS worked!(I) Scheduling of regional public health conference calls cannot be done by emailSafety and Security(Improvement): (Clark) Information did not always flow well within the public health DOC.(S) Safety officer seemed very involved; very knowledgeable(I) Law enforcement involvement in the exercise could have been beneficial(I) Need a detailed explanation of job duties in ICS response(I) Consider Safety of staff, our offices, staff, panic button, lock door, deliver medsUtility System(If applicable: generators, IT, etc.)(Improvement): (Region) There were multiple sites complaining of communication issues where phone lines did not roll over and radio use was causing computer issues.(I) Mental Health Services to develop in-house building notification phone tree for emergencies(I) Need to consider how to back up our EMRPaper forms, satellite radio(I) Slow moving technology makes communication difficultCommunication(Improvement): (Region and Clark) There is a need across the region for better information to partners about medical surge issues within the hospitals.(Strength): (Region) Regional health commissioner’s conference call was completed within the first hour ensuring all local health departments were operating from the same information.(Strength): (Region and Clark) Redundant interoperability using MARCS radios was established early between hospitals and local health departments during the exercise.(Strength): (Region and Clark) Health Alert Network (HAN)/ OPHCS was used to get key incident response information to partners.(Strength): (Clark) EMA was able to assist with information sharing to partners particularly in acting as a liaison with Law Enforcement.(Improvement): (Region and Clark) It was observed at multiple locations that information was not being readily shared with all partners dealing with the response.(Improvement): (Region and Clark) There was confusion on messaging concerning SNS assets and the cache maintained by ODH.(I) Section and command staff leaders need routine briefings(I) Continuity of Operations: Key players were eliminated, so unsure how to proceed; Share extensive understanding of aspects of response so that positions can be manned even with loss of employees(I) Communicating current objectives needing to be addressed(I) providing detailed info to allow all responders to be informed and carry out their tasks(I) Partners need more reputable communication and more often; updates would be good; Possibly a central site for information and situational awareness(I) Do more regular “battle rhythm” entire room briefings; hourly, etc. (S) Opportunity for OPHCS and OPOD was good. I feel prepared to deal with them again for nowCommand Structure(This is not considered a critical area according to The Joint Commission, but has been included as a point of emphasis based on previous exercises)(Strength): (Region) Numerous locations identified that IC within HICS/DOC provided situational update on hourly basis.(Strength): (Clark) Good success and evidence of use of ICS forms, particularly for communicating general messages and closing circle for resolution. Forms utilized included ICS 214, 213 RR, 213, 205, 206, etc. See Attachments.(Strength): (Region and Clark) All local health departments had solid Strategic National Stockpile (SNS) plans in place and were readily available and used during the exercise.(Improvement): (Region and Clark) Need for establishing additional closed PODs.(Strength): (Region) Hospitals utilized medical students, volunteers and extra staff to support the response.(I) Change of staff confusing/ change of roles(I) Staff update meeting needed once an hour or so; There wasn’t a good structure set up where all the commands meet together to ensure on the same page(I) Better understanding for the group of when to go into ICS- prior to this react as a normal response. (S) Mental Health Services demonstrated planning to set up in-house crisis center in board room for incoming calls of concern and identify staff to man the calls Management of Cases or Patients(Strength): (Clark) Health care organizations in Clark County demonstrated robust agency level responses from Healthcare Organizations playing in Clark County (i.e. shelter in place, lockdown, supply line alternatives, use of corporate assets.)(Strength): (Clark) Hospice and Mental Health Services demonstrated plans to support other partner agencies by providing additional services as part of the community’s response due to multiple deaths.(Strength): (Clark) Partner Healthcare Organizations communicated frequently with Communicable disease unit regarding individual case information. This is evidenced by documented 213 and 214 forms created during the exercise. This strength is separate from the gap noted in areas for improvement, which speaks to situational awareness.(Strength): (Clark) Partners very interested in Closed POD and began to create dispensing plans for staff and clients. This included agencies that had residential clients as well as agencies with clients in the community such as Hospice.(I) Mental Health Services to work with SRMC for process for medical clearance for suicidal patients during disaster(S) Hospice: Each RN has a number of patients they are assigned to – responsible to keep informed and assess and deliver ATBResources(Improvement): (Region) Kindred hospital was overlooked as a resource for freeing up inpatients from other hospitals.(Improvement): (Clark) Animal and Agriculture resources need to be available for consult; partners expect this kind of information from public health.(Improvement): (Clark) EMA could be utilized more to obtain assets needed to set up PODS or receive material.(Improvement): (Region and Clark) Demonstrated that processes were in place for contacting and requesting volunteer resources for assistance during need. In Clark County, the Volunteer Reception Center (VRC) was requested and mentioned in the Volunteer Management Plan.(Strength): (Region and Clark) Planned for the opening of a volunteer reception center to ensure additional volunteers would be available when needed.(Improvement): (Region and Clark) Increase number of volunteers available.(Improvement): (Region and Clark) Identify backups for primary volunteer coordinators.(Improvement): (Clark) Need to exercise VRC once more(S) 213 RR preferred over 215 for resource managementDue to simulation cell limitations, unsure how resources would play out (paraphrased)(I) Use EMA in resource management when appropriate(S) Was able to discuss getting supplies for “PODS”(I) Need breakdown of staff needs in PODS. (I) need more staff (I) Hospice:13 counties we cover for resourcesStaff Knowledge(Improvement): (Region) Delay with some hospitals dealing with in-patient units assessing potential discharges and transfer out of hospital.(Improvement): (Clark) Need increased familiarity with the regional biological and epidemiology plans.(Strength): (Clark) In review of exercise documentation, there was evidence of research and outreach regarding safety of responders both internal to CCCHD and external such as first responders. This is in line with the Public Health Preparedness capabilities. In example, the type of PPE and disinfection processes for tularemia were available due to research to establish a known profile of the biological threat.(Strength): (Region and Clark) The majority of health departments quickly accessed the states standing orders for recommendations.(Strength): (Region and Clark) It was identified that ODH maintained a cache of antibiotics that could be requested by locals before the SNS was requested.(Improvement): (Region and Clark) Understanding of what the ODH cache is and what it is available for.(Improvement): (Region and Clark) Requests to pharmacies as dispensing sites and regional Points of Dispensing need much more review.(Improvement): (Clark) There is a need for more familiarity with the Strategic National Stockpile assets, including what medications should be requested for prophylaxis.(Improvement): (Region and Clark) Details involved with the requesting process for the SNS.(I) Newer staff had a lot of questions to ask; Cross Divisional Training would be a good way to answer those questions(I) Public Health Staff had no job action sheets; need specific delegated tasks (I) Set up hourly communication notice process for staff(S) Knowledgeable staff in Communicable Disease(I) Need to educate community partners’ staff of large scale incident ................
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