NBU Capacity Drill January 8 2015 Exercise Planning

NBU Capacity Drill January 8, 2015

Exercise Planning Team • Brian Madison, Exercise Outreach Coordinator • Nebraska Biocontainment Drill Committee • Phil Smith MD • Angela Vasa RN • Kate Boulter RN • Beth Beam RN, Ph. D • Karen Roesler RN • Jerry Nevins RN

Life Support Issues • • • Phones/Pagers Restrooms Emergency Exits Other Safety Information Breaks

Agenda • • Exercise Structure and Format Player and Facilitator Roles Exercise Rules STARTEX

Purpose The purpose of the exercise is to evaluate and review the activation process for the Nebraska Biocontainment Unit when admitting 10 patients with febrile respiratory illness.

Exercise Objectives • Evaluate the process of triage, holding and treatment in the ER related to multiple HID patients presenting from the community. • Evaluate the strategy inclusive of Douglas County Public Health for activating the NBU for confirmed HID of respiratory nature. (Mers Co-V) • Evaluate the capability of Nebraska Medicine to support the activation of the NBU with equipment and supplies for 10 respiratory HID patients. • Evaluate the plan for relocating the satellite lab within the NBU to an offsite location within 4 hours when operating with 10 bed capacity. • Evaluate the effectiveness of the waste processing and removal protocol in the NBU for respiratory illness. • Evaluate the effectiveness of the PPE donning and doffing plan when caring for 10 respiratory HID patients.

Exercise Structure & Format • Discussion Based Exercise (Tabletop) • Briefing • Discussion Period • Report – out • Repeat the process

Facilitator Roles • Guide the discussion • Ensure that responses are recorded for inclusion in the after action report • Act as general information resources (if needed)

Exercise Rules • Respond based on what you know (your understanding of your agency’s Disaster Plans and your knowledge of other existing plans and capabilities) • Answers given are not carved in stone • Assume realistic cooperation and support from responders and other public agencies • Issue identification is not as valuable as suggestions and recommended actions that could improve response and preparedness efforts. Problem – solving efforts should be the focus

Capacity Drill Tabletop Exercise January 8, 2016 Startex

Module 1 At 0500 this morning the NBU nursing leadership received a call from Dr. Smith, advising them to prepare to accept as many as 10 patients. Dr. Smith called from the ED, where he was evaluating Mr. Orange, a 47 -year-old Caucasian male who presented to the ED with a 4 -day history of fever (as high as 102. 8 F), chills, rigors, headache, myalgia, and a non-productive cough. He has developed increasingly severe shortness of breath over the past 12 hours. A CXR obtained in the ED demonstrates patchy bilateral interstitial infiltrates.

Module 1 Continued • A fourth-year medical student working in the ED had earlier elicited the following history: • On Christmas Eve, Mr. Orange had played the role of a Wise Man in a living nativity pageant presented by a local Church. While rehearsing, a live camel imported in order to add realism to the pageant, sneezed in Mr. Orange’s face, as well as the faces of the two other Wise Men. • Upon further questioning, Mr. Orange notes that he lives in Omaha with his wife; his 24 -year-old son lives with them, and they share the home with his 79 year-old mother-in-law. • Mr. Orange’s wife, mother-in-law and son accompanied him to the hospital and have also been placed in isolation. • His brother-in-law, Mr. Blue, has been visiting for the Holidays, along with his wife and two children (ages 11 and 2). Of note, Mrs. Blue is pregnant with their third child. All have developed a cough over the past few days. • They are en route to the ED due to development of symptoms to include fever of 101. 8, chills and increasing difficulty breathing.

Module 1 Questions 1. How will the ED accommodate 8 potential HID isolation cases without interrupting flow of the ED? 2. When do we contact the additional 2 Wise Men? 3. When do we contact Public Health? 4. What is the role of public health at this juncture? 5. What role does security play at this point? * Consideration-the patients refuse to stay in isolation while awaiting test results. 6. Does the ED need to have any special considerations for waste handling?

Module 2 • ED staff isolated the patient and his immediate family members in the Emergency Department after realizing the potential for the presence of Mers Co-V. • Public Health Department has been notified of the situation. • ED staff collected nasopharyngeal specimens and they have been sent to the Public Health Lab for testing. • Mr. Orange’s wife has called the additional 2 men and informed them that they have been put into isolation at Nebraska Medicine. • The 2 men have decided to proceed to the Emergency Department.

Module 2 cont. • At 0930 Dr. Smith is notified by the Nebraska Public Health Lab that all four of the specimens they received have tested positive for Mers Co-V. • Dr. Smith then notifies the NBU Leadership team of the results of the tests and to proceed with activation of the Biocontainment Unit. • NBU Nursing Director and Manager have reported to the ED to provide support and assess the situation. • Lead nurse has notified staff to report to the unit with the intention of staffing 4 patients immediately, another 4 probable patients with an additional possibility of 2 admissions, to be determined depending upon lab results.

Module 2 Questions 1. How does public health track down the contacts of these individuals? What do they advise these individuals? 2. What is the monitoring process for employees after transfer of the patients from the ED? After discharge from the NBU? 3. How long would it take to prepare the unit to accept 10 patients? * Consider moving the lab, clearing the rooms, cleaning the rooms, stocking supplies, installing patient equipment. 4. How will the ED prepare to hold 10 HID isolation patients until the NBU is ready to admit all patients? 5. At what number of admissions do we consider moving the lab a necessity? * If we don’t move it at notification of positive patients what do we do with the BSC?

Module 3 • At 1000 the first of the staff have reported to the unit and initiated the activation checklist. • Delivery of necessary equipment, supplies, medications and safety checks have been initiated. • NBU manager has spoken with the ED manager to update on the timeline and that the NBU will be ready for the first patient by 1200.

Module 3 Questions 1. What would be the best way to transport to the NBU? What is security’s role in transport and what PPE will they wear? *Consider varying acuity-include increased dyspnea, agitated children, uncontrolled coughing, weakness or inability to ambulate. 2. Semi-Private room accommodations • Do we place family together? Children with parents? Curtains in place for HIPPA? Room movement for acuity? 3. Should staff doff in between patient rooms? • Consider not doffing out of every room, change gloves, shoe covers and perform hand hygiene in between rooms. • What does this mean for the ED care flow? 4. Where should the doffing take place? *Consider a designated zone just past the nurse’s station and before the first patient care room. *Educate staff on need to use the 7213 anteroom for all entry and exit into that room to diminish risk of equalization of negative pressure. *Consider the risk of performing procedures such as x-ray in the room closest to the nurses station.

Module 3 Questions cont. 6. Will staff be allowed to work in their home units while caring for Mers Co-V patients? Can they go home after end of shift? 7. Tele-health presence from Incident Command rather than the nurse’s station? * Consider the use of Vidyo for MD, PT, non-essential staff in conference room 8. How do we process waste? Linens? • Consider not autoclaving and passing the waste from the room (hot) to the warm (hallway) into a second bag and then from warm into cold into a waiting trash cart for waste disposal. • Designated removal times? • Store waste in room? • If we do autoclave where would we store the waste prior to autoclaving?

Module 4 • At 1400 Dr. Smith receives notification that the second two men who presented to the ER have also tested positive for Mers Co-V. • The previous eight patients have all been admitted to the unit and NBU staff are working on completing the assessments, admission profiles and providing essential care to the patients. • NBU Staff are notified of the additional 2 admissions. • Additional staff are donned and verify the rooms are prepared for patient admission.

Proposed Pt Placement Room Placement: • 7215 -Sister-in-law (pregnant) and 2 year old • 7219 - Brother in law and 11 year old • 7223 - Mr. Oranges Wife and 78 year old Grandma • 7225 -Mr. Orange and 24 year old son • 7229 -man 1 and man 2

Module 4 Questions 1. Should the husband wife be admitted into the same room? Or comply with gender segregation? Should each parent be placed into a room with each child? 2. What is public health’s role at this time? What/how are we communicating to the community? 3. Will the patients be allowed to leave their rooms and visit family members in neighboring rooms? 4. How will we facilitate communication between rooms? 5. What if one parent recovers and is ready to discharge but the children and spouse are not able? 6. If acuity drastically changes do we move patient rooms? 7. What is the process for handling the coordination of care of the deceased? *Considering family members are cohabitating the NBU

Module 5 -Functional Portion • NBU Staff will proceed to the NBU to address the secondary objectives of this drill. • Thank You all for your participation and valuable feedback.

Hotwash

Please Complete your Evaluations • Thank You!! • Any questions can be directed to: Brian Madison brian. madison@unmc. edu or at 402 -552 -9724