AFTER ACTION REPORT

Coordinated Multi-State

Pandemic Influenza

Tabletop Exercise

Wednesday, November 15, 2006

Wide Open Spaces

Public Health Collaborative

Colorado, Kansas, Nebraska, Wyoming

Executive Summary

A global pandemic influenza outbreak represents one of the most catastrophic threats to the U.S. public health system. In the 20th century, three major pandemics were caused by the emergence of several new influenza A virus subtypes that resulted in over 600,000 deaths in the United States (U.S. Centers for Disease Control and Prevention [CDC], 2005).

New influenza “A” virus subtypes, similar to the ones that caused the pandemics of the 20th century, are likely to emerge in the 21st century as well. Medical advances and public health preparedness efforts have improved the nation’s abilities to respond to a pandemic influenza emergency even as dramatic increases in global travel and the demand for poultry have made the United States more vulnerable to such threats.

In preparing for such a threat, public health agencies must work closely with a number of partners, including emergency management agencies, law enforcement agencies, elected officials, and healthcare agencies and providers.

This tabletop exercise was intended to test the relationships between partners, in response to a pandemic flu emergency.

The exercise was led by a facilitator who presented participants with chronological segments of a scenario separated by a series of discussion points that enabled participants to describe how they would respond to the evolving scenario at isolated points in time. The exercise facilitator was aided by a note taker and a local resource person who was responsible for assisting or backing up the facilitator.

The exercise relied on a “forced decision-making” framework, which requires participants to make key decisions at each discussion point after they have had time to consider the scenario and the information provided to them at a specified point in time.

The exercise focused on five broad issue areas:

  • Surveillance and Epidemiology
  • Command, Control, and Communications
  • Risk Communication
  • Resource Coordination

The exercise consisted of three sections:

  • Unfolding Situation--Decisions and Responses; A new influenza A subtype has been spreading from person to person in countries in Southeast Asia and initially materializes in the United States in Florida. Participants are required to discuss the steps they would take to prepare for the disease before it spreads to their jurisdiction.
  • Later Developments--Decisions and Responses; he disease spreads to Nebraska. Participants are required to discuss everything from how they would initially detect the disease’s presence in their community, to how they would mitigate the disease’s effect on their community, to how they would manage, distribute, and administer a vaccine for the disease.
  • Debriefing and Self-Evaluation; Participants reflect on the exercise experience and discuss strengths and areas for improvement. Participants are then asked to identify the three most important gaps that they identified and to outline concrete, short-term plans for beginning to address these gaps.

Participants were encouraged to develop short - and long-term plans for all of the gaps identified.

Major Strengths of the exercise included:

  • The participants of all agencies involved demonstrated an excellent ability to recognize the difficulties of dealing with a pandemic flu emergency.
  • The participants demonstrated a positive attitude and ability to recognize and react to shortfalls in planning as they were uncovered.
  • Each state understood its own reporting system and had an excellent understanding when to include state Heath and Human Services System.
  • Local Health Departments were comfortable with surveillance communication across state lines, on the local level, and stated they would be conducting emails and phone calls with cross border partners as situations developed.

In addition, several successes of this exercise should be recognized, among them:

  • This was the first major exercise of this nature that included Colorado, Kansas, Nebraska, and Wyoming.
  • It was a major, and positive, undertaking to gather this many partners on a video conference to deal with pandemic flu emergency issues.

Through the exercise, several opportunities for improvement in the ability to respond to a pandemic flu incident were identified:

  • It was unclear how states would communicate with one another on the state level and who would be the lead in sharing information.
  • There was no clear command structure in place across state lines. The exercise was designed to be played without a declared emergency, or EMAC assistance. Without this declared emergency at the state level, it would be very difficult to coordinate the activities of the four player-states. Each state should determine what would realistically take place in this scenario at their respective state and national levels to determine what support would be available.
  • It was clear that, while informal communication between the states was excellent, there is a lack of formal agreements on how health districts should deal with pandemic flu issues across their states borders. It is recommended that each state should revisit the scenario, to explore the possibility of working with local, state and federal agencies in an emergency.

Part 1: Exercise Overview

This exercise was a teleconference table top with multiple locations in each of the participating states of Colorado, Kansas, Nebraska and Wyoming.

Jurisdiction Information:

The Mid-America Alliance and the Nebraska Emergency Management Agency (NEMA) participated in an administrative and facilitative role.

Exercise Name: Wide Open Spaces, Coordinated Multi-State Pandemic Influenza

Type of Exercise: Tabletop

Duration: 3 hours

Exercise Date: November 15, 2006

Sponsor: Mid-America Alliance

Focus:Response

Location: Multiple locations in Colorado, Kansas, Nebraska and Wyoming

Participating Organizations:

Public Health:

Colorado

Larimer County Department of Health and Environment

Weld County Department of Public Health and Environment

Northeast Colorado Health Department

KitCarsonCounty Health and Human Services

LincolnCounty Public Health

CheyenneCounty Public Health

ProwersCounty Public Health

Kiowa CountyNursing Service

Baca CountyNursing Service

Kansas

Cheyenne County Health Department

Hamilton County Health Department

Morton County Health Department

Sherman County Health Department

Stanton County Health Department

Nebraska

Southwest Nebraska Public Health Department

Panhandle Public Health Department

Two Rivers Public Health Department

Wyoming

AlbanyCounty Public Health Response Coordinator (Region 3)

LaramieCounty Public Health (Region 7)

Region 7 Laramie, Goshen and PlatteCounties

Fire/HazMat:

Colorado

Union Colony Fire and Rescue Authority

Burlington Fire Protection District

Kansas

MortonCounty Fire Department

Emergency Medical Services (EMS):

Colorado

KitCarsonCounty Emergency Medical Services

WeldCounty Paramedic Service

Kansas

StantonCounty Emergency Medical Services

MortonCounty Emergency Medical Services

Wyoming

American Medical Response (AMR)

Medical:

Colorado

KitCarsonCountyMemorialHospital

HighPlainsCommunityHealthCenter

NorthColoradoMedicalCenter

SE Hospital and LongTermCareCenter

SterlingRegionalMedicalCenter

PoudreValleyHospital

McKeeMedicalCenter

KeefeMemorialHospital

EstesParkMedicalCenter

Bent CountyCoroner

KitCarsonCounty Coroner

Kansas

MortonCountyHospital

StantonCountyHospital

GoodlandRegionalMedicalCenter

Nebraska

CommunityHospital

TriValleyHospital

DundyCountyHospital

PerkinsCountyHospital

Wyoming

PlatteCountyHospital

GoshenCountyHospital

AlbanyCountyHospital

CarbonCountyHospital

CheyenneRegionalHospital (Formerly United MedicalCenter)

Communications/Dispatch:

Colorado

KitCarsonCountyCommunicationsCenter

ProwersCountyCommunicationsCenter

WeldCountyCommunicationsCenter

Kansas

StantonCounty Sheriff Office

Wyoming

WDHEmergencyOperationsCoordinationCenter

Law Enforcement:

Colorado

Burlington Police Department

KitCarsonCounty Sheriffs Dept

LarimerCounty Sheriff Office

Kansas

StantonCountyLaw Enforcement

Wyoming

LaramieCounty Sheriffs Dept

Cheyenne Police

Wyoming Highway Patrol

Emergency Management

Colorado

Greeley Emergency Management

LincolnCounty Office of Emergency Management

LoganCounty Office of Emergency Management

City of Loveland Emergency Management

LarimerCounty Emergency Management

KitCarsonCounty Office of Emergency Management

ProwersCounty Office of Emergency Management

YumaCounty Office of Emergency Management

Colorado Division of Emergency Management, SE Field Staff

Kansas

CheyenneCounty Emergency Management

ShermanCounty Emergency Management

StantonCounty Emergency Management

MortonCounty Emergency Management

HamiltonCounty Emergency Management

Nebraska

FurnasCounty Emergency Manager

Nebraska Emergency Management Agency

Wyoming

AlbanyCounty Emergency Management (Region 3)

LaramieCounty Emergency Management (Region 7)

Universities/School Districts

Colorado

University of Northern Colorado

ColoradoStateUniversity

Nebraska

University of Nebraska

Wyoming

Department of Education

Public Works, other local agencies

Colorado

Department of Social Services, ESF 6, SE Region

KitCarsonCounty Health and Human Services (Social Services Branch)

LarimerCounty PIO Consortium

Kansas

Southwest Kansas Health Initiative

StantonCounty Commissioner

Morton County Commissioner

Morton CountyPIO

Nebraska

Mid-America Alliance

Wyoming

VA Infection Control

VA Safety/Security

LaramieCountyCommunity College Epidemiology Students

MENTAL HEALTH

Colorado

Centennial Mental Health

Policy and Government

State

Colorado

Colorado Department of Public Health and Environment

Kansas

Kansas Department of Health and Environment

Nebraska

Nebraska Department of Health and Human Services

Wyoming

Wyoming Department of Health

Wyoming National Guard

Office of Homeland Security

Health and Human Services

Department of Transportation

RETAC/LEPC, etc.

Colorado

Plains-to-Peak RETAC

Northeast Region Homeland Security

Kansas

Southwest Kansas Regional Homeland Security

Nebraska

South Central Regional LEPC

Exercise Overview: This exercise was designed to offer an opportunity to discuss a four-state response to pandemic influenza; as well as simultaneously review local and regional Pandemic Influenza plans in Colorado, Kansas, Nebraska and Wyoming.

It was designed to assist in identifying planning components and public health response structures that may impede or confound the ability of bordering counties to assist or work with one another.

Since epidemiological events can be long term and require numerous agencies, a multi-disciplinary approach is required to plan for and respond to these health threats. It was also intended to give those participating an opportunity to become informed about on-going planning efforts and will be used to assist in building relationships on an interstate level.

Exercise Evaluation: The focus of the exercise was to enable participants to assess current response capabilities of a pandemic or epidemiological incident requiring communication and coordination of Risk Communications among border counties of Kansas, Colorado, Nebraska and Wyoming, identifying strengths and weaknesses, and identifying future training needs. The exercise focused on key local emergency responder coordination, critical decisions, and the integration, where appropriate, of interstate communication. Evaluators were positioned at all exercise locations to assist in the overall identification of issues.

Evaluators: Evaluators worked as a team with Site Facilitators. They did not interact with players. Evaluators recorded events and ensured documentation was submitted for review and inclusion in the After-Action Report (AAR)/Improvement Plan (IP). Evaluators did not interfere with the integrity of the exercise or players. All questions raised during the exercise were to be addressed by the Site Facilitator.

Handbooks and Evaluation Forms: An F/E Handbook was used to guide the conduct and evaluation of the exercise. Evaluation forms were provided to the evaluators to assist in capturing the highlights of this exercise. The Exercise Evaluation Guides (EEGs) were used and referred to in case questions or discrepancies arose.

Chapter 2: Exercise Goals and Objectives

The following were the major exercise goals:

  • Policy issues affecting public health response either positively or negatively on an interstate level
  • Roles of participating agencies in a Pandemic
  • Gaps in preparedness and coordination
  • Identification of related training/learning needs

The following were the exercise objectives as outlined in the EXPLAN for this exercise. It should be noted that the format of this EXPLAN is from the Homeland Security Exercise and Evaluation (HSEEP) Toolkit. The objectives in this EXPLAN are formatted in such a way as to suggest an operations based exercise (functional or full-scale). The objectives in the EXPLAN were very ambitious. Typically in a tabletop exercise one would expect to focus on a limited number of objectives, perhaps three to seven.

From the document titled: Coordinated Multi-State, Pandemic Influenza, Tabletop Exercise, EXERCISE PLAN (EXPLAN), Final Version 4.0 10/31/2006, Prepared by: Dawn James, RN/MSN-C:

Major Exercise Goals and Objectives

Note: Exercise Objectives are linked to the CDC Pandemic Influenza work plan guidance.

  • In addition to the major goals and objectives listed below it is hoped the following will be discovered:
  • Policy issues affecting public health response either positively or negatively on an interstate level
  • Roles of participating agencies in a Pandemic
  • Gaps in preparedness and coordination
  • Identification of related training/learning needs

Goal A:Evaluate tactical communications capabilities across

state lines (between public health and partner entities

via HAN, Fax, e-mail, radio, etc.)

Tactical Communication Objectives:

I. Planning

WOS Table Top Objective 1:

Bordering agencies (public health officials, hospitals, emergency managers, MD officers, etc) will clearly and effectively identify how to communicate with each other (fax, email, phone, etc) designating key local authorities and stakeholders engaged in the planning and executing of local pandemic response.

Performance Measure(s):

  1. Results of post-exercise evaluation of the resource directory by border agencies who utilized the directory to communicate information of public health importance with border counties, including information on status of school and public event closures.
  1. Results of post-exercise evaluation of bordering agencies understanding of key local and bordering agency authorities and stakeholders engaged in pandemic influenza response.

CDC 1A::CTb: Plans must delineate accountability and responsibility for key local authorities and stakeholders engaged in planning and executing specific components of the operational plan (e.g., identification, isolation, quarantine, movement restriction, healthcare services, emergency care, mutual aid and school closure).

______

II. Detect and Report

WOS Table Top Objective 2:

Bordering agencies will notify state agencies of information received across state lines in a timely manner.

Performance Measure(s):

  1. Local public health agencies will discuss processes for notifying the state following a receipt of a call about an event that may be of urgent public health consequence. Discussion will include the turn-around time for such communication.

CDC 3A, 4A: Decrease the time needed to detect and report an influenza outbreak with pandemic potential.

CDC 4A, 1: Support exchange of essential information before and during an influenza pandemic. Coordinate procurement and placement of technology communication systems that, based on gap analysis of requirements versus existing capabilities, are compliant with PHIN preparedness Function Area Partner Communication and Alerting.

WOS Table Top Objective 3:

Bordering agencies will follow their state agencies terms and conditions for the use of secure communications channels of each state’s Public Health Information Network or Health Alert Network.

Performance Measure(s):

  1. Local agencies will understand and discuss the distribution guidelines as defined by alerts issued through state health alert networks in the exercise.
  2. Local agencies will discuss the process for seeking appropriate approval and for sharing the information in the alert with the bordering jurisdictions.

CDC 4A, 2: Have access to interoperable information systems that support the initial identification and that provide situational awareness of possible pandemic influenza outbreak in compliance with PHIN Preparedness Functional Area Early Event Detection.

a)Receive, triage and send case or suspect case disease reports 24/7/365.

b)Receive health related data from multiple data sources to monitor, quantify and localize aberrations to normal data patterns

WOS Table Top Objective 4:

In the event of a public health emergency that extends beyond the border agency’s jurisdiction and extends across state-lines, the border agency will be able to identify how to share reports across jurisdictions and multiple-levels of public health ensuring restricted information is only available to intended recipients.

Performance Measure(s):

  1. Local agencies will discuss the process used to define and count confirmed probable or suspect cases and the best means to share information on counts.
  1. Local agencies will discuss the process used to collect and share reports received on information obtained from multiple data sources including but not limited to veterinary systems, school absenteeism reports, hospital utilization data, nurse call lines and over-the-counter drug sales.

______

III. Medical Surge

WOS Table Top Objective 5:

Bordering agencies (public health officials, hospitals, emergency managers, MD officers, etc) will clearly and effectively communicate with each other (fax, email, phone, etc) about the operating status of hospitals.

Performance Measure(s):

Local agencies will identify the key person or position responsible for the dissemination or receipt of information on the status of the county hospitals and discuss the turn-around time for the communication.

CDC 6A, 1B: Exercise communication systems, plans and procedures to ensure that hospitals, health care systems and public health inform the community about the operating status of hospitals and the triggers for sending a person to the hospital

______

IV. Isolation and Quarantine

WOS Table Top Objective 6:

Bordering agencies will communicate on criteria used for isolation and quarantine and methods used to support service and monitor those affected by containment measures.

CDC 6B, 6: Develop and exercise an operational plan for isolation and quarantine that delineates the following:

a)The criteria for isolation and quarantine

b)The procedures and legal authorities for implementing and enforcing these containment measures, and

c)The methods that will be used to support, service, and monitor those affected by these containment measures in healthcare facilities, and other settings

WOS Table Top Objective 7: