Hazardous Material Tabletop Exercise

Hazardous Material Tabletop Exercise Master scenario events list (MSEL) Prepared by: With funding support from: Office of Assistant Secretary for Preparedness and Response (ASPR) Hospital Preparedness Program through the Massachusetts Department of Public Health Office of Preparedness and Emergency Management i HSPH-EPREP

PREFACE The purpose of the is to provide central exercise facilitation team members a complete edition of the MSEL. This includes the summary listing as well as any detailed inject forms that will be delivered to players. Core control team members may use this document to track exercise play, manage Simulation Cell (SimCell) functions, and maintain situational awareness for the Exercise Director. Evaluators may also reference individual pieces of the document through teamwork with facilitators. Exercises are the culmination of training toward a higher level of preparedness. This document was produced with help, advice, and assistance from planning team members from various departments and agencies. The information in this document is current at the date of publication and is subject to change as dictated by the Exercise Planning Team. ii HSPH-EPREP

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CONTENTS Preface...i Handling Instructions... Error! Bookmark not defined. Exercise Objectives...1 Overall Objectives...1 MSEL (Expanded) Module 1 - Initial Response and Awareness...3 Module 2 - Operations, Part 1...6 Module 3 Operations, Part 2... 11 Module 4 - Demobilzation and Recovery... 17 iv HSPH-EPREP

Overall Objectives EXERCISE OBJECTIVES 1. Discuss relevant protocols and procedures involved in obtaining and deploying CHEMPACK assets. 2. Examine key assumptions and actions that relate to hospital-based decontamination during a HAZMAT incident. 3. Assess the communication systems and networks used during a large-scale hazardous materials event that support field and hospital situational awareness regarding the responders' capability to respond. 4. Name best practices in the flow and care of contaminated and uncontaminated patients, visitors and medical personnel to the hospital during the event. 5. Identify essential recovery issues related to the incident, including the supplies, staff and resources needed to demobilize and return to normal operations. 1 HSPH-EPREP

Event # 1 Event Time: December 9, 2011-8:45am TTX Time: March 16, 2012-5:45pm Recipient Player(s): All Players Event Description: Establishes the starting point related to events that will serve as catalysts for subsequent preparatory/response activities Inject: Date and Time: Friday, March 16 th, 2012 at 5:45pm. Weather: It is overcast, 45 degrees, and there is a 40% chance of precipitation. Winds are out of the West at 5mph. A recent thaw has melted the last snowfall. Location: A high school located approximately 25 minutes from your facility. A high school in a nearby town is hosting a basketball game between their team and a neighboring rival. Attendance at the game is estimated at 650 people. At 5:45pm, during the half-time break, fans seated in the visiting team bleachers begin coughing, experiencing difficulty breathing, and vomiting. Other fans begin drooling, experiencing headaches, blurred vision, tearing, and feeling tightness in their chest. Multiple fans call 9-1-1 from their cell phones and State Police is inundated with calls for help at the high school. At 5:46pm, a student inside the gymnasium pulls the fire alarm. There are two police officers at the event on a detail for security and traffic control who are the first responders on scene. Assisted by school teachers and staff, the officers attempt to evacuate the building and keep fans from leaving the scene. The senior police officer directs local dispatch to alert responding units that there is a suspected hazardous material incident at the school and the cause is unknown. The officer states that a large number of people at the high school are having difficulty breathing and some have reported smelling a sulfurous odor in the gymnasium. Additional Police, Fire, and EMS units begin to arrive on scene at the high school at 5:50pm. Teachers at the school report to responders that they think everyone is out of the building. The ranking Fire Officer on scene confirms with the town dispatcher that there is a potential hazardous materials incident at the high school with a large number of people sick or injured and assumes incident command. Summary: There is a possible hazardous material incident at a local high school where a basketball game was being held. The crowd is estimated at 650 people. 2 HSPH-EPREP

Expected Action(s): Notes Responders should recognize the need for additional assets and the importance of early notification of nearby hospitals. Module 1- Initial Response and Awareness Key Issues Responders should recognize the scale of the incident and disseminate notifications. Responders and hospitals should activate plans and mobilize assets to respond. Information sharing should be established between hospitals and first-responders. Responders should classify the unknown hazardous material. Situational Awareness General Discussion Questions 1. When do first-responders notify local hospitals of a potential Mass Casualty/Hazardous Materials Incident? a. *What triggers first-responders to notify hospitals of an incident? b. *Who on scene contacts hospitals? How do they contact hospitals? c. *What specific information do hospitals need? d. *Which hospitals do they contact? e. *When and how often do they provide updates? f. What information do responders share? g. How are hospitals getting this information? 2. What is your hospital s response to notification of a potential MCI/HAZMAT incident? a. *What are your hospital s initial priorities? Who is in charge at this point? b. *What are your hospital s actions before the HAZMAT incident is confirmed? c. How do you receive confirmation of a HAZMAT incident? 3. What information do hospitals need to share with first-responders? What information do hospitals need to share with DPH? What information do hospitals need from DPH? a. Who produces this information? b. How is it shared? c. How often is it updated? 3 HSPH-EPREP

d. How is this information compiled to maintain a common operating picture and regional situational awareness? 4. What monitoring of available information do hospitals conduct on a daily basis? a. Is there ongoing surveillance of HHAN, NWS alerts, and/or first-responder radio channels at your hospital? b. Would your hospital hear about an event through informal means of communication (social media, friends) before formal communication? c. How would your hospital address these rumors? 4 HSPH-EPREP

Event # 2 Event Time: December 9, 2011-9:00am TTX Time March 16, 2012-5:55pm Recipient Player(s): All Players Event Description: More definitive information that will continue play and challenge participants during response. Inject: The audience at the game has evacuated the building and many people are crowded outside the school. The audience has used several different exits to exit the school and the crowd is dispersed throughout the parking lot and nearby playing fields. The majority of the crowd is presenting with difficulty breathing, drooling, and decreased vision. Several patients appear to have difficulty ambulating. First-responders are directing everyone who exited the school toward the decontamination site that they are creating. The Police Department is establishing a perimeter around the school closing off the surrounding roads. Emergency Medical Services is preparing to triage, treat, and transport patients. A staging area is designated, and additional Police, Fire, and EMS resources responding to the scene are directed to check in and await assignment. The Incident Commander has requested mutual aid assistance and on-scene decontamination capability. EMS personnel are beginning to treat patients who have gone through decontamination. The EMS supervisor notifies the Incident Commander that, based upon the signs and symptoms of patients, he believes that they have been exposed to a nerve agent and there is a need for CHEMPACK assets. The Incident Commander requests that CHEMPACK assets be activated and deployed to the scene. Summary: EMS personnel have identified that signs and symptoms of patients are potentially consistent with a nerve agent. The Incident Commander has requested CHEMPACK assets be activated and deployed to the scene. It is unclear how many fans have been affected; first-responders are trying to direct the crowd through the gross decontamination the Fire Department has set up and away from the school. Local assets are overwhelmed by the initial response and have requested mutual aid from the surrounding communities 5 HSPH-EPREP

Expected Action(s): Notes Local dispatch should request the deployment of CHEMPACK assets. Host-site hospitals should discuss their plans for distributing CHEMPACK assets. Non-host site hospitals should discuss their plans for receiving assets. Discussion should focus on how to rapidly access and deploy CHEMPACK assets. Module 2- Operations, Part 1 Key Issues Early notification should occur between hospitals that an incident requiring CHEMPACK assets has occurred. Participants should discuss how to request and coordinate the deployment of CHEMPACK assets from host-site hospitals to appropriate locations. Participants should discuss how to develop a common operating picture through information sharing between hospitals and first-responders. Obtaining CHEMPACK General Discussion Questions 1. When would you activate your EOP in this scenario? a. *What is the trigger to activate your EOP? b. How would this decision be made? Who makes the decision? 2. What does your Incident Command structure/organization look like at this point? a. How will you rapidly compile, verify and share information/reports? b. What mechanisms are you using to send/receive information from local public safety and local public health representatives? c. What specific information do you need? d. Who are you informing about your plans and status? What information are you sending? When are you sending it? 3. What is your plan for obtaining CHEMPACK resources? a. *What is the trigger to access these resources? b. *How will Incident Command or EMS communicate the need for CHEMPACK assets in the field? c. *How will non-host hospitals communicate the need for CHEMPACK assets at their facility? 6 HSPH-EPREP

Deploying CHEMPACK d. *How do host facilities communicate the need for additional CHEMPACK assets at their facility? e. *Do hospitals have redundant and resilient forms of communicating the need for CHEMPACK assets? f. *Who has the authority to access CHEMPACK resources? Is there always someone onsite who can make this decision? g. *What scale nerve agent incident would overwhelm your capability to manage patient health? h. What security measures do you put in place when you are notified of an incident requiring CHEMPACK assets? i. Who has the key to the room or cage that the CHEMPACK container is stored in? Who has the key to the containers? Where are they stored? j. With whom do you coordinate opening and distributing CHEMPACK assets? k. Do you conduct training with your staff and partners on CHEMPACK? l. How often do you inspect CHEMPACK containers and assess their readiness? m. How long do you have to notify DPH that a CHEMPACK container has been opened? n. Do host hospitals verify the need with EMS or non-host hospitals before opening CHEMPACK supplies? o. What written policies and procedures do you have regarding a potential nerve agent incident? Do your clinicians know these policies and procedures? p. Do hospitals and EMS have interoperable forms of communication? q. Do all agencies in your region use common language when communicating by radio? 4. How are CHEMPACK assets mobilized in your region? a. *Who is responsible for distributing the supplies in a CHEMPACK to their appropriate location? i. In-hospital transport to a loading area? ii. Transport from host hospitals to non-host hospitals? iii. Transport from host hospitals to the incident scene? b. *What vehicles are used? Who requests these vehicles and how? How many are needed? c. *Are there sufficient emergency vehicles in your region to handle the immediate response to the scene and to rapidly transport CHEMPACK assets? d. *Has an agency been pre-identified as being responsible for transporting CHEMPACK assets? e. *Are loading areas for CHEMPACK resources and vehicles pre-identified? 7 HSPH-EPREP

i. Are they in an area that is likely to be free of contamination? ii. Can these areas be secured? iii. Who manages these staging areas? iv. How are assets and responders directed to these locations? f. *How long will it take to transport assets between host and non-host hospitals? g. *Where do CHEMPACK assets go for pick up at host hospitals? h. *Where do CHEMPACK assets go for delivery at non-host hospitals? i. *Is the loading zone co-located with the ambulance bay at your facility? Will regular operations or decontamination operations interfere with distributing CHEMPACK assets? Is the loading zone secure? j. *How do you allocate supplies among host hospitals, non-host hospitals, and EMS during a response? i. Which boxes stay with the host hospital/go to non-host hospitals/go to the scene? ii. Are resources at host hospitals dedicated for a specific non-host hospital? iii. Can you subdivide non-host site resources (blue tags) for more than one hospital? iv. Can you subdivide EMS resources for more than one scene? v. How do you determine which non-host site hospitals receive tagged boxes if there are multiple non-host hospitals requesting CHEMPACK assets. k. Are there predetermined staging locations for packages of medication that are intended for field or non-host site hospital use? l. Who receives CHEMPACK resources at your facility? m. Who oversees the distribution of tagged boxes to appropriate parties? Who handles completing the Transfer of Custody forms? n. Are the individuals responsible for preparing boxes for transportation familiar with the Transfer of Custody forms? Who is authorized to fill out these forms? 5. How do you communicate with your partners about CHEMPACK status? a. With other hospitals? With responders on scene? b. How often are updates going out? How is this information disseminated? c. What process do you have in place for coordinating the flow of CHEMPACK data? i. Who is responsible for tracking CHEMPACK deployment? ii. What information is collected? iii. How is it collected? iv. How is it stored and transmitted? 8 HSPH-EPREP

v. How are you maintaining a regional or statewide awareness of what is occurring? vi. Do you have any functional system for communicating regionally with your partners? vii. What information would you need to know? How would you get that information? viii. How do you determine if additional CHEMPACK resources are needed on scene or at other hospitals? 6. What information are you looking for from DPH and/or local public health authorities and what information are you providing to them? When and how are you communicating with them? 7. Are you performing an assessment at this point? a. Have your hospital s priorities changed based on new information? b. Is someone assessing critical personnel and material resource needs? How long will this take? c. Do any decisions need to be made before the assessment is completed? 9 HSPH-EPREP

Event # 3 Event Time: December 9, 2011-9:45am TTX Time: March 16, 2012-6:00pm Recipient Player(s): All Players Event Description: More definitive information that will continue play and direct participants to focus on hospitalbased decontamination. Inject: It is fifteen minutes after the beginning of the incident. A situation update from Incident Command via online information sharing tool: Summary: o Many fans are known to have bypassed the decontamination zone that responders established and were able to get to their vehicles and leave the scene. It is unknown how many were exposed to the potential toxic agent. o As of 6:00pm the Police Department has established a perimeter around the school controlling traffic and is attempting to contain patients. o It is unknown how many people fled the scene; however, responders estimate the remaining crowd at the school to be between 300 and 400 people. o The Fire Department is setting up their on-scene mass decontamination. o Staging, treatment, and transport areas have been established and EMS has begun transporting critical patients to the closest hospitals. o DPH is asking local hospitals to report their status and decontamination capability. o Ambulances have been depatched to the nearest CHEMPACK host-site hospital to transport CHEMPACK assets to the nearest non-host site hospital and to the scene. o Local media is en route to the high school and is already reporting that a nerve agent has been released at the high school. o Transit buses have been requested to serve as temporary shelters for decontaminated individuals, but they have not arrived. Their estimated time of arrival is within the hour. It is expected that anyone with symptoms will be taken to a hospital. An unknown number of contaminated individuals fled the school before the scene could be contained. These individuals are expected to be heading for the nearest hospitals which are approximately 25 minutes away from the high school. EMS and hospitals still need to receive CHEMPACK assets. Mutual aid Police/Fire/EMS units are responding to the high school to assist local responders. Hospitals should not expect immediate assistance from Police/Fire/EMS. 10 HSPH-EPREP

Expected Action(s): Notes Hospitals should prepare to receive an influx of critical patients and large numbers of patients suffering minor illnesses. Many patients may not be decontaminated prior to arrival. Decontamination operations should be set up at the hospital with facilities secured and staff instructed to wear appropriate PPE. On scene responders and hospitals should communicate and coordinate so patients are transported to the most appropriate facilities. Module 3 Operations, Part 2 Key Issues Hospitals should prepare to be inundated by contaminated patients self-presenting to their facilities. Local public safety resources will be overwhelmed by the initial on scene response. Hospitals should not anticipate immediate assistance from local Police/Fire/EMS. Communication between hospitals and on scene incident command will be crucial to coordinate patient treatment and transport to the most appropriate facilities. Responder safety and patient care must be maintained during the operations. Coordinating the timely release of public information and warnings will be challenging. General Discussion Questions Hospital Decontamination 1. What information is being shared between the scene and hospitals now? a. How are you getting this information? b. How quickly are you getting the information you need? c. What information is most crucial for hospitals and responders to know? 2. Are there formalized stages in your hazardous materials response plan with defined actions? a. *If so, what are those actions? b. *Who is directing operations at end stage? 3. Describe your plans for setting up a Mass Decontamination Unit at your hospital? a. *What triggers you to prepare for decontamination operations? i. How do you alert your hospital staff? 11 HSPH-EPREP

ii. How do you alert first-responders? iii. Do you notify DPH? Other Hospitals? b. *Do you rely upon support from external partners to conduct decontamination operations? c. *Who decides to prepare for decontamination? 4. What security measures do you put in place when you are notified of a HAZMAT incident? a. *How do you secure your facility? b. *How many staff does it take to secure your facility? 5. *How long does this take both during the day and during off hours? (record time) 6. How long does it realistically take for you to set up your MDU? (record time) a. *Where does this staff come from? b. *What is the minimal number of staff you need to set up your MDU? c. *How long does it take for your staff to suit up in PPE? (record time) d. *What do you do with contaminated patients if they arrive before your MDU is set up? e. *What is the minimal number of staff you need to operate your MDU? f. *What is the pressurized water source for your MDU? Do you have alternatives? 7. Who do you notify that you have started decontamination operations? a. *How do you make this notification? b. *What information do you share? 8. How do you determine the appropriate level of PPE for your staff to don? a. *Who selects and maintains your PPE? b. *Who is trained to wear PPE at your facility? c. *What level PPE are they trained on and equipped with? d. *Are people capable of providing security trained to wear PPE? e. *Are people capable of conducting triage trained to wear PPE? f. *Are people who are capable of providing treatment such as auto-injectors trained to wear PPE? Up to what level? g. *Do you have sufficient staff on 24/7 to provide these services and continue normal or surge operations? h. *Can you provide sufficient medical personnel to staff prescreening area, disrobing area, decontamination area, gowning area, and a triage area? 12 HSPH-EPREP

i. How long do allow staff to work in PPE? i. During normal conditions? ii. During extreme heat or cold? iii. How do you monitor staff health? j. What is your response plan for an injured staff member in the decon area? i. How do decon members communicate? Verbally/Non-verbally? ii. Do you have a safety officer? k. How is the use of PPE prioritized during the response? i. How have you identified the amount and types of additional PPE needed to support your response? ii. Where can you get additional PPE during a response? How long does this process take? l. What do you do if you need responders in Level B PPE (SCBA)? 9. How do you decontaminate: a. *Non-ambulatory people, individuals who require additional assistance, and children? b. *Service animals or pets? c. *Critically injured individuals who require therapy throughout decontamination? d. *How do you track and securely store personal belongings? e. *What items do you allow patients to take with them through decon? 10. At what rate can your MDU decontaminate: (patients per hour)? a. *Ambulatory patients? b. *Non-ambulatory patients? c. *How long can you maintain operations at this rate? What factor limits your response capability (decon staff, PPE, fuel)? 11. What is your response to a contaminated person in your hospital? 12. How do you provide shelter for contaminated patients waiting to go through decontamination? 13. How do you establish triage and patient tracking during decontamination? 14. What do you do with patients who are not injured and have gone through decontamination? 15. How are you initially assessing adequacy of inventory of key material resources and existing supplies? a. What are the challenges in defining these resources? 13 HSPH-EPREP

Patient Flow b. Is there a plan for automatically conducting/submitting unit-level resource needs/utilization reports? What is the trigger for units to submit such reports? Who is compiling the reports? How long will it take? How is the information updated? c. Do you have caches of critical supplies related to mass decontamination? Where are they and how are they accessed? What critical supplies will likely run out first? 16. How do you adapt your decontamination plan to changing events/weather? a. Extreme temperatures? b. Severe weather? c. A power outage? 17. How do you manage patient flow at your facility? a. *How do you demarcate the hot zone, warm zone, cold zone? b. *Does your hospital identify a prescreening area, disrobing area, decontamination area, gowning area, triage area? c. *Who do you allow to bypass decontamination? d. *How do you manage traffic flow at your facility? e. *How do you identify vehicles with contaminated patients? Where do they park? f. *How do you handle accepting other, non-contaminated ED patients during the event? g. *How do you direct contaminated patients from hospital entrances to the decontamination area? h. *How would you ensure that contaminated individuals go through decontamination before entering the hospital? i. *How do you handle other hospital visitors, patients, and staff arriving at your facility during the event? j. *How will patients arriving by EMS be directed to decontamination? k. *What information do you relay to people trying to seek help at the hospital? l. *How do you communicate with non-english speakers who arrive at your hospital? m. *How do you communicate with people with disabilities who arrive at your hospital? 18. How do you distinguish contaminated patients from uncontaminated patients? a. *Who conducts this screening? b. *Where are they positioned? 14 HSPH-EPREP

c. *What PPE are they wearing? 19. What are your primary methods of internal and external communication? a. What external agencies/entities are you communicating with at this point? b. What information do you need from them and what information are you giving them? c. How are you interacting with EMS? With LPH? With public safety? 20. Who takes the lead for risk communication with staff internally? With patients and families? 21. What is your understanding of the role of DPH and emergency management agency during a hazardous materials event? How will the hospital IC structure coordinate/communicate with DPH and emergency management agency during the response? 15 HSPH-EPREP

Event # 4 Recipient Player(s): Event Description: Event Time: December 9, 2012-10:30am TTX Time: March 16, 2012-11:00pm All Players Incident summary and additional information that will direct participants to focus play on recovery issues. Inject: It is just over five hours since the incident began. A small device was found underneath the bleachers in the high school gymnasium that appears to have dispersed a chemical and an investigation is underway to determine who planted the device. Preliminary test results have confirmed that the liquid in the device is a concentrated organophosphate pesticide. In total, 298 patients showed signs and symptoms of nerve agent exposure and were transported from the scene. An additional 334 patients self-presented to the two closest area hospitals complaining of signs and symptoms of nerve agent exposure. The majority of these cases were unfounded. Fortunately, many fans were not in the gymnasium during half-time when the nerve agent was released and were able to evacuate before being exposed. A significant amount of CHEMPACK supplies remain unused both at hospitals and with EMS at the scene. All patients showing signs and symptoms of exposure to the nerve agent have been decontaminated either on scene or at area hospitals. Sixty-four patients are in serious or critical condition following the incident. Many of these patients are pediatric and had to be intubated. Families are contacting local hospitals trying to locate their family members. Identifying patients has been complicated by the decontamination process. The combination of the scale of the incident and the large amount of pediatric patients has resulted in significant stress among responders and hospital staff. Several of your staff members lived in the nearby town and are familiar with victims. In addition, there is a significant amount of media interest in the incident and response from both local and national outlets. Your staff members report being asked questions from reports while coming and going to work. Summary: A large number of patients are in serious or critical condition following the incident and will require ongoing intensive care at area hospitals. There are CHEMPACK assets that were deployed but not used during response at both hospitals and the incident scene. Mass Decontamination Units and the areas used for decontamination at hospitals need to be restored as soon as possible to allow normal operations to resume. 16 HSPH-EPREP

Expected Action(s): Participants should discuss the procedure for inventorying and properly storing deployed CHEMPACK assets. Hospitals should discuss the steps they would take to demobilize their MDUs and restore their facilities to normal operations. Notes Module 4 - Demobilization and Recovery Key Issues Patients are being stabilized, observed, discharged, and transferred as is appropriate. Several patients will require ongoing therapy to counter the effects of the nerve agent. Many family members and friends are still attempting to locate their loved ones. Hospitals will need help facilitating these connections. CHEMPACK assets will need to be handled appropriately and added to existing pharmaceutical supplies. Reports will need to be filed by public health regarding the response and activation of CHEMPACK assets. Samples should be taken and sent to the state lab. Agencies will need to work together to determine the cost of the response and, if possible, file for reimbursement. Recovery Issues General Discussion Questions 1. What are your priorities at this point? Who determines them? 2. Do you have policies and procedures in place for absorbing unused CHEMPACK assets into your pharmaceutical supplies? a. *Who accepts these resources? b. *Where do they go? c. *How are they inventoried and stored? 3. How do you safely clean and restock your MDU? a. *Who is responsible for restoring the MDU? b. *How long does this process take? c. *What decontamination services are available at your facility in the interim? d. *How do you safely dispose of waste water? e. *How do you dispose of contaminated clothing? 17 HSPH-EPREP

f. *Do you have procedures in place for decontaminating personal belongings and returning them to their owners? 4. How do you decontaminate your facility and property? a. *How much area do you need to decontaminate? b. *How long will it take to decontaminate this area? c. Who is responsible for this process? d. What actions are involved? 5. How long will it take to restore your ED to normal operations? 6. Are you prepared to handle the mental health of the public and your staff following an incident of this nature? a. What specific services will you provide? b. How would you manage a large number of people seeking mental health services? c. Is your staff aware of these resources? d. To whom are these resources available? 7. What agencies are you coordinating recovery with? What information are you sharing? a. What support do you need from DPH? From other hospitals? From the private sector? From nongovernmental organizations? b. When does the transition to normal operations begin? 8. Who has the authority to make the decision to transition back to normal operations? a. What is the process to make this transition? b. Are there defined triggers? c. Who is involved in this process? 9. Do you have policies and procedures in place to facilitate family linking for large numbers of unidentified patients? a. How do you facilitate this link? b. Who is responsible for this process? c. When does this process start? How long do you estimate this process will take for each patient? 10. How do you handle media inquires? a. Do you have a PIO assigned? b. Will you allow media on site? c. Are your staff trained to handle media inquires or direct media to the PIO? 18 HSPH-EPREP

Event # 5 Event Time: December 9, 2011-11:00am Recipient Player(s): All Players Event Description: END EXERCISE 19 HSPH-EPREP