AFTER ACTION REPORT/IMPROVEMENT PLAN

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Kern County Statewide Medical-Health

Functional Exercise

November 18, 2010

A

FTER

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CTION

R

EPORT

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MPROVEMENT

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LAN

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A

DMINISTRATIVE

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ANDLING

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NSTRUCTIONS

1. The title of this document is the Kern County Statewide Medical-Health Functional Exercise

After-Action-Report/Improvement Plan (AAR/IP). 2. Points of Contact:

Ross Elliott, EMS Director

Kern County Public Health Services Department 1800 Mount Vernon Avenue

Bakersfield, CA 93306 661-321-3000 (office) [email protected] Exercise Coordinator:

Russ Blind, EMS Coordinator

Office of Public Health Preparedness

Kern County Public Health Services Department 1800 Mount Vernon Avenue

Bakersfield, CA 93306 661-321-3000 (office) [email protected]

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C

ONTENTS

ADMINISTRATIVE HANDLING INSTRUCTIONS ...2

SECTION 1:EXERCISE OVERVIEW ... 11

SECTION 2:EXERCISE DESIGN SUMMARY ... 14

SECTION 3:ANALYSIS OF CAPABILITIES ... 18

SECTION 4:CONCLUSION ... 50

APPENDIX A:IMPROVEMENT PLAN ... 52

APPENDIX B:EXERCISE EVENTS SUMMARY TABLE ... 57

APPENDIX C:PERFORMANCE RATING ... 64

APPENDIX D:CALIFORNIA HEALTH ALERT NETWORK (CAHAN) ... 69

APPENDIX E:ACRONYMS ... 74

Important Note: This document was developed using the Department of Homeland Security HSEEP AAR/IP 2007 template. The template should not be modified to maintain HSEEP compliance.

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E

XECUTIVE

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UMMARY

The Kern County Statewide Medical-Health Functional Exercise 2010 was held on November 18, 2010, from 0800 hours to 1130 hours, followed by a hot-wash session with all participating organizations. This exercise in Kern was part of the statewide annual medical-health exercise program managed through the California Department of Public Health (CDPH) and California EMS Authority (EMSA). The statewide 2010 main scenario was an Improvised Explosive Device (IED).

The primary objectives established by CDPH and EMSA are as follows:

1. Testing the ability of emergency response partners within the OA to share critical information in planning for and responding to an IED;

2. Determining whether technology and plans for ensuring ongoing communications during an IED event are adequate;

3. Identifying the capacity and capability to respond to a mass casualty event with forensic implications and resource sharing, including personnel and equipment responding to an event with blast, trauma, burn and pediatric injuries; and,

4. Testing resource requesting procedures consistent with the California Standardized Emergency Management System.

In addition to these objectives, we wanted to test communications between Hospital Command Centers, Clinic Command Centers, and Skilled Nursing Facility (SNF) Command Centers to the Public Health Services Department Operations Center (Public Health Services DOC), mass decontamination at least at two hospitals, and mass casualty surge equipment set-up.

Based on these needs, it was determined that one or more IEDs would not be sufficient to trigger mass decontamination or mass casualty surge. So we elected to add another twist to the scenario of cyanide powder dispersal with IEDs at multiple hospitals.

The exercise design was managed by the Kern County Public Health Services Department (KCPHSD) through the Core Exercise Design Team which is part of the Disaster Medical Planning Group (DMPG). DMPG is Kern’s forum for disaster medical planning, training, and exercises. The Core Exercise Design Team initially met monthly after each DMPG meeting to develop the exercise. In October 2010, weekly Core Exercise Design Team meetings were held. Core Exercise Design Team members were as follows:

Russ Blind, KCPHSD Steve Chambers, KCPHSD Marilyn Hallman, KCPHSD Carolyn Forster, KCPHSD Ron Csech, KCPHSD

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Jeanette Smart, Mercy Hospital

Brian Patrick, Bakersfield Heart Hospital Brian Pasqua, Bakersfield Heart Hospital Joshua Sharp, Bakersfield Memorial Hospital Susan Asche, Clinica Sierra Vista

AJ Ledoux, Glenwood Gardens SNF

Bob Easterday, San Joaquin Community Hospital Ross Kelly, Bakersfield Fire Department

Sean Pratt, Kern County Sheriff’s Office Bomb Squad Donna Fenton, Kern County Environmental Health Nick Herndon, Kern County Fire Department Sean Collins, Kern County Fire Department Michele Trams, Kaiser-Permanente

Kim Rodriguez, KCPHSD

With 22 different participating organizations, this was the largest medical-health exercise ever held in Kern. Each hospital, clinic and SNF determined their level of play which ranged from bomb threat receipt and search; up to a simulated explosion, cyanide dispersal, mass

decontamination, and mass casualty surge equipment deployment. The following shows the extent of exercise play:

IED, Explosion, Decon, Surge -Kern Medical Center -San Joaquin Hospital -Bakersfield Heart Hospital -Bakersfield Memorial Hospital -Mercy Hospital

-Mercy Southwest Hospital

IED Search, DOC Communications -Tehachapi Hospital

-Good Samaritan Hospital -Ridgecrest Regional Hospital -Kern Valley Hospital

-Kaiser

-Clinica Sierra Vista -Delano District SNF -Glenwood Gardens SNF -Golden Living Center SNF -HealthSouth BRRH

Allied Responding Agencies

- Kern County Sheriff Bomb Squad - Kern County Fire Department - Bakersfield Police Bomb Squad - Bakersfield Fire Department

- Kern County Environmental Health

Department Operations Center

- Kern County Public Health Services

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The scenario included the following:

• Bomb Threats to 11 Hospitals, 3 SNFs, 1 Clinic, 1 Kaiser Clinic

• Explosion & Cyanide Dispersal at 6 Hospitals

• 120 Simulated Victims (18 Red, 45 Yellow, 57 Green)

• Resource requests through Medical-Health Mutual Aid System: 223 Cyanokits, 60 RNs, 40 MDs, 5 Ambulance Strike Teams

• Full Scale Haz-Mat, Bomb Squad, Mass Decontamination, Mass Casualty Surge Deployment at Kern Medical Center and San Joaquin Hospital

• Communications between the KCPHSD – DOC and each Hospital Command Center, Clinic Command Center, SNF Command Center

• HAvBED Drill – 100% for Kern

• KMRC Alert, Staging, and Deployment

• Regional & State Medical-Health Mutual Aid System Requests (simulated)

The exercise started at 0800 hours on November 18, 2010 and concluded at 1130 hours; followed by a hot-wash session. Results were analyzed based upon a Facilitator Evaluation Form that was completed by each hospital, clinic and SNF. The Facilitator Evaluation Form consisted of 14 different components for healthcare facilities:

1. Bomb Threat Actions 2. Facility Search 3. Facility Lock Down

4. Communications – Internal

5. Communications – Public Health Services DOC

6. Communications – On-Scene Fire, Law, Ambulance (with facility staff) 7. Facility Staff use of Personal Protective Equipment (PPE)

8. Hot Zone Establishment/Containment 9. HVAC Shut Down

10.Triage

11.Decontamination

12.Surge Equipment Mobilization 13.Resource Ordering

14.ICS Organizing, Command, Control

The Public Health Services Department Operations Center had different components for analysis. Those included:

1. ICS Organizing

2. Situation Status Assessment 3. Resource Status Tracking 4. Communications – Internal 5. Communications – External 6. Incident Action Planning

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7. Use of the Medical-Health Mutual Aid System 8. Command and Control

9. Noise 10.Space 11.Displays

Organizations self-scored their performance. Depending on the level of play, many of the components would be not applicable. Each component was numerically ranked on a scale of zero to 4 defined as:

N/A: Not Applicable

0 – No Action: Not done and was indicated 1 – Poor: Done – but major problems noted 2 – Fair: Done – but moderate problems noted 3 – Good: Done – no significant problems noted 4 – Excellent: Done – exemplary action noted

The following shows the overall average scores of all organizations combined within each of the components:

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The results generally indicate systemic needs in further guidance, training and exercises;

particularly in the areas of resource ordering, surge equipment mobilization, facility lock-down, and staff use of personal protective equipment. On-scene communications, facility search, triage, and bomb threat actions ranked quite high from a systemic perspective.

The following shows each organization’s overall performance (by self-scoring):

The Public Health Services Department Operations Center, consisting of Public Health, EMS, and Environmental Health staff, was also analyzed numerically by group consensus. The results are as follows:

Total Scores:

Total Points Poss Score Average Percent

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The current DOC location is obviously too small and not equipped properly. Efforts are underway to configure a much larger DOC facility.

A more detailed analysis of each organization’s performance is in Section 3 of this report. Overall, this was a highly positive exercise experience with exemplary participation.

Major Strengths

The major strengths identified during this exercise are as follows:

On-Scene Communications with Fire, Law, Ambulance (with facility staff) Facility Search (for a bomb threat)

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Primary Areas for Improvement

Throughout the exercise, several opportunities for improvement Kern’s ability to respond to the incident were identified. The primary areas for improvement, including recommendations, are as follows:

Resource ordering (more definition of the process and forms)

Surge equipment mobilization (staff training in surge equipment use) Facility lock-down (more planning and training)

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S

ECTION

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E

XERCISE

O

VERVIEW

Exercise Details

Exercise Name

Kern County Statewide Medical-Health Exercise 2010

Type of Exercise

Functional Exercise

Exercise Start Date

November 18, 2010

Exercise End Date

November 18, 2010

Duration

4 hours

Location

Multiple sites in Kern County

Sponsor

Kern County Public Health Services Department

Program

2010 California Statewide Medical-Health Exercise Program

Mission

Alert, response, and operations related to multiple bomb threats at healthcare facilities in Kern County.

Capabilities

Health Care Facility Capabilities:

10.Triage

11.Decontamination

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Public Health Services DOC Capabilities:

1. ICS Organizing

Scenario Type

Improvised Explosive Devices (multiple) with Cyanide Dispersal

Exercise Planning Team Leadership

Russ Blind, KCPHSD – Exercise Coordinator Steve Chambers, KCPHSD

Marilyn Hallman, KCPHSD Carolyn Forster, KCPHSD Ron Csech, KCPHSD Barbara Swanson, KCPHSD

Lon Lancaster, Kern Medical Center Jeanette Smart, Mercy Hospital

Brian Patrick, Bakersfield Heart Hospital Brian Pasqua, Bakersfield Heart Hospital Joshua Sharp, Bakersfield Memorial Hospital Susan Asche, Clinica Sierra Vista

AJ Ledoux, Glenwood Gardens SNF

Bob Easterday, San Joaquin Community Hospital Ross Kelly, Bakersfield Fire Department

Sean Pratt, Kern County Sheriff’s Office Bomb Squad Donna Fenton, Kern County Environmental Health* Nick Herndon, Kern County Fire Department Sean Collins, Kern County Fire Department Michele Trams, Kaiser-Permanente

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Participating Organizations

IED, Explosion, Decon, Surge -Kern Medical Center -San Joaquin Hospital -Bakersfield Heart Hospital -Bakersfield Memorial Hospital -Mercy Hospital

-Mercy SW Hospital

IED Search, DOC Communications -Tehachapi Hospital

-Good Samaritan Hospital -Ridgecrest Regional Hospital -Kern Valley Hospital

-Kaiser

-Clinica Sierra Vista -Delano District SNF -Glenwood Gardens SNF -Golden Living Center SNF -HealthSouth BRRH

Allied Responding Agencies

- Kern County Sheriff Bomb Squad - Kern County Fire Department - Bakersfield Police Bomb Squad - Bakersfield Fire Department

- Kern County Environmental Health

Department Operations Center

- Kern County Public Health Services

Department

Number of Participants

Players: Total not Assessed Controllers: 5

Evaluators: 22 Facilitators: 22 Observers: 8

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ECTION

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XERCISE

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ESIGN

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UMMARY

Exercise Purpose and Design

The purpose was to participate in the 2010 Statewide Medical-Health Exercise Program and test response, communications, operations, intelligence gathering, situation status assessment, resource status tracking, mass decontamination, mass casualty surge deployment, and resource requests through the California Medical-Health Mutual Aid System.

The exercise was designed based upon the statewide scenario of an Improvised Explosive Device (IED). Cyanide dispersal was integrated into the exercise scenario to trigger mass

decontamination, Haz-Mat and Bomb Squad responses, mass casualty surge equipment

deployment, and resource requests through the California Medical-Health Mutual Aid System.

Exercise Objectives, Capabilities, and Activities

Capabilities-based planning allows for exercise planning teams to develop exercise objectives and observe exercise outcomes through a framework of specific action items that were derived from the Target Capabilities List (TCL). The capabilities listed below form the foundation for the organization of all objectives and observations in this exercise. Additionally, each capability is linked to several corresponding activities and tasks to provide additional detail.

Based upon the identified exercise objectives below, the exercise planning team has decided to demonstrate the following capabilities for Health Care Facilities (HCF) during this exercise:

10.Triage

11.Decontamination

A separate set of capabilities were set for the Public Health Services DOC for this exercise: 1. ICS Organizing

2. Situation Status Assessment 3. Resource Status Tracking

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4. Communications – Internal 5. Communications – External 6. Incident Action Planning

Scenario Summary

On November 18, 2010 at 0800 hours a series of telephone bomb threats are received by each Hospital Emergency Department in Kern, several clinics, Kaiser-Stockdale, and several skilled nursing facilities in Kern. The male subjects (multiple) warn that a chemical bomb will be detonated at 0830 hours. The subjects make no demands and quickly hang up.

Hospitals call 911, activate their bomb threat plans, and begin to search for and suspicious objects at each facility. Several hospitals contact EMS on-call staff, provide notice of the bomb threat, and request disaster closure. On-Call EMS staff realize that this threat involves most, if not all, hospitals in Kern. EMS On-Call staff contact the Kern County Sheriff‟s Department and Bakersfield Police Department; and determine all hospital EDs, several skilled nursing facilities, and several clinics have received the bomb threats. Hospitals, clinics, and skilled nursing

facilities activate their Command Centers.

A decision is made to activate the Public Health Services DOC to track the situation; and Kern County OES is notified. Communications are established with each facility to the Public Health Services DOC with a request for regular situation status updates.

At 0815 hours, a suspicious package is located in a trashcan in the Kern Medical Center Emergency Department Waiting Room. It is a box with wires extending to two plastic bottles filled with some form of a powder. 911 is called, the KMC waiting room, and ED are in the process of being evacuated. The Public Health Services DOC is notified. The Public Health Services DOC notifies all hospitals and clinics of the device discovery at KMC. Law

Enforcement, a Bomb Squad, and Fire Department are responded.

At 0820 hours, a suspicious package is located in a trashcan in the San Joaquin Hospital Emergency Department Waiting Room. It is a box with wires extending to two plastic bottles filled with some form of a powder. 911 is called, the SJH waiting room, and ED are in the process of being evacuated. The Public Health Services DOC is notified. The Public Health Services DOC notifies all hospitals and clinics of the device discovery at SJH. Law

Enforcement, a Bomb Squad, and Fire Department are responded. At 0830 hours, explosions occur at:

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Mercy Hospital Emergency Department Waiting Room

Mercy Southwest Hospital Emergency Department Waiting Room Bakersfield Heart Hospital Emergency Department Waiting Room San Joaquin Hospital Emergency Department Waiting Room

Following the explosions, a rather large cloud of orange dust is dispersed at each site that covers many people. Not many are injured by shrapnel. But several are exposed at each site. A few minutes later, victims closest to the explosion begin complaining of nausea, light-headedness, and difficulty breathing; with a taste of bitter almonds on their breath.

Cyanide exposure is suspected. This is reported to the Public Health Services DOC by KMC. Law Enforcement, Fire Department (including Haz-Mat), and Ambulances are responded to each site where an explosion occurred. Environmental Health is also responded to each site where an explosion occurred. The following number of exposures are reported to the Public Health Services DOC:

KMC ED: 15 Exposures Total – 5 Red, 5 Yellow, 5 Green Mercy ED: 27 Exposures Total – 2 Red, 15 Yellow, 10 Green Mercy SW ED: 22 Exposures Total – 2 Red, 10 Yellow, 10 Green Memorial ED: 20 Exposures Total – 2 Red, 6 Yellow, 12 Green Heart ED: 16 Exposures Total – 3 Red, 3 Yellow, 10 Green SJH ED: 20 Exposures Total – 4 Red, 6 Yellow, 10 Green Total: 120 Exposures Total – 18 Red, 45 Yellow, 57 Green

Bomb searches at the other hospitals and facilities are continuing. All Hospital Command Centers and Clinic Command Centers are activated and reporting updates to the Public Health Services DOC. Kern County OES is notified and the Kern County Operational Area EOC is activated. The Public Health Services DOC notifies the Region-5 Regional Disaster Medical Health Specialist and advises that the Medical-Health Mutual Aid System will be activated. The Kern Medical Reserve Corps is alerted to respond to the Kern County Public Health Services Department to stage. A CAHAN alert is issued to CDPH-EPO and EMSA by the Public Health Services DOC.

KMC Hospital Command Center requests 8 CyanoKits; or the equivalent of Sodium

Thiosulfate, Sodium Nitrite, Amyl Nitrite for 8 people to the Public Health Services DOC. . Memorial Hospital Command Center requests 40 CyanoKits; or the equivalent of Sodium Thiosulfate, Sodium Nitrite, Amyl Nitrite for 20 people to the Public Health Services DOC. They also request 10 ED physicians, 15 RNs with ED experience.

Mercy Hospital Command Center requests 60 CyanoKits; or the equivalent of Sodium Thiosulfate, Sodium Nitrite, Amyl Nitrite for 27 people to the Public Health Services DOC. They also request 10 ED physicians, 10 RNs with ED experience, and 4 Paramedic Ambulances.

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San Joaquin Hospital Command Center requests 40 CyanoKits; or the equivalent of Sodium Thiosulfate, Sodium Nitrite, Amyl Nitrite for 20 people to the Public Health Services DOC. They also request 10 ED physicians, 15 RNs with ED experience.

Kaiser locates a suspect device, but it does not detonate and remains un-exploded. Hot zones are established at each location and mass decontamination units are set-up. Fortunately, no further explosions occur.

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S

ECTION

3:

A

NALYSIS OF

C

APABILITIES

This section of the report reviews the performance of the exercised capabilities according to exercise facilitator observations and ranking on the Facilitator Evaluation Form. This form was used to provide a measurable tool to analyze exercise performance in the following areas:

Health Care Facility Capabilities:

10.Triage

11.Decontamination

Public Health Services DOC Capabilities:

1. ICS Organizing

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Health Care Facility (HCF) Capability 1: Bomb Threat Actions

Capability Summary: Evaluate the healthcare facility (HCF) response to a bomb threat issued by telephone and policy compliance.

1. Bomb Threat Actions:

N/A No Action 0 Poor 1 Fair 2 Good 3 Excellent 4

KMC 2 SJH 3 BHH 3 BMH 4 Mercy 3 Mercy SW 2 RRH 4 GSH 3 TVHD 3 KVH 3 Delano District SNF 3

Golden Living Center SNF 0

Glenwood Gardens SNF 3

Clinica Sierra Vista 3

Kaiser 3

BPD Bomb Squad N/A

Average: 2.80

Comments: KMC - Used radio to alert of bomb. KVH - Could improve in policy knowledge. CSV - Staff responded explaining what they would do, utilized copy of bomb threat phone report. Glenwood - Associates had a general knowledge of the steps needed to be taken. BMH - Internal communication and notification was excellent. Kaiser - All facilities responded very well with the exception of one. They took down all the information and did not notify anyone about the bomb threat.

0 0.5 1 1.5 2 2.5 3 3.5 4

Bomb Threat Actions

Bomb Threat Actions

Observations 1.1: Strengths:

All participating HCFs have bomb threat protocols that were followed.

San Joaquin Hospital provided a bomb threat form and protocol that was provided to all participating HCFs before the exercise.

Overall, this was ranked very high in performance.

Areas for Improvement:

None noted for systemic improvement.

References:N/A

Analysis: With little exception, this capability was ranked very high.

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HCF Capability 2: Facility Search

Capability Summary: Evaluate the healthcare facility (HCF) ability to search the facility to locate suspected IEDs.

2. Facility Search:

KMC 3 SJH 4 BHH 3 BMH 4 Mercy 3 Mercy SW 2 RRH 4 GSH 3 TVHD 3 KVH 3 Delano District SNF 1

Kaiser 3

Average: 3.00

Comments: SJH - Need to have Command Center dispatch person to handle response to IED found.

KVH - Searched all waiting areas, no device found. CSV - Discussion at each site re: places to search for a bomb, what to look for, etc.. GSH - All managers reported search all clear to IC.

Glenwood - Hesitation to complete search internally if in actual situation. BMH - Although the bomb was not located (per exercise design), the ED department staff and security did an excellent job conducting the search and identifying suspicious items. Kaiser - 5 bombs were located throughout our facilities and all responded very quickly and appropriate with the exception of one of our facilities who had trouble locating the bomb.

0 0.5 1 1.5 2 2.5 3 3.5 4 Facility Search Facility Search Observations 2.1: Strengths:

All participating HCFs conducted a facility search for suspected IEDs. Some HCFs had multiple simulated IEDs to be located.

With few exceptions noted above, all HCFs located the simulated devices. Overall, this was ranked very high in performance.

References:N/A

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HCF Capability 3: Facility Lock Down

Capability Summary: Evaluate the healthcare facility (HCF) ability to lock down and secure the facility.

3. Facility Lock-Down:

KMC 4 SJH 2 BHH 2 BMH 3 Mercy 3 Mercy SW 3 GSH 2 RRH 0 TVHD 2 KVH 2

Delano District SNF N/A

Clinica Sierra Vista N/A

Kaiser N/A

Average: 2.17

Comments: SJH - Discussed and simulated. KVH - Did not lock-down; manned entrances.

Glenwood - Most associates knew to lock down building immediately. BMH - This was good. BMH is considering revising procedure to involve more staff similar to our child/infant abduction

procedures. Limited security staff would not be able to effectively monitor all entrances/exits. Kaiser

- Unable to conduct facility lock down due to patient care.

0 0.5 1 1.5 2 2.5 3 3.5 4 Lock-Down Lock-Down Observations 3.1: Strengths:

All participating HCFs conducted some form of facility lock down or staffing entry points to secure the facility.

Some HCFs have extreme challenges in locking down the facility because of multiple points of entry.

As noted above, some HCFs may need to involve more staff in facility lock down and securing the facility because there is not enough security staff to cover all points of entry.

References:N/A

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HCF Capability 4: Communications - Internal

Capability Summary: Evaluate the healthcare facility (HCF) ability to communicate within the facility with staff.

4. Communications – Internal:

KMC 1 SJH 2 BHH 4 BMH 2 Mercy 1 Mercy SW 1 GSH 3 RRH 3 TVHD 1 KVH 3 Delano District SNF 2

Kaiser 3

BPD Bomb Squad 3

Average: 2.44

Comments: KMC - Emergency cell phones non-opereational. SJH - Need to work on multiple channels and radio ettiquette. KVH - Used two-way radios; telephones for sensitive info. CSV - Sites utilized internal FAX communication tool. Glenwood - Clearly defined chain of command for communication. BMH - Fair. Still need work on internal resource requesting and documentation.

Kaiser - Overall communications went well – need work on command center.

0 0.5 1 1.5 2 2.5 3 3.5 4 Internal Comm Internal Comm Observations 4.1: Strengths:

All participating HCFs conducted internal communications related to the exercise with staff.

CAHAN was used successfully by some HCFs and the Public Health DOC.

Comment: While individual HCFs note internal areas for improvement, there are no known „systemic‟ policy, guideline, or training related needs.

References:N/A

Analysis: With little exception, this capability was ranked very high. Lower rankings were not substantiated with comments or details from some HCFs.

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HCF Capability 5: Communications – Public Health Services DOC

Capability Summary: Evaluate the healthcare facility (HCF) ability to communicate with the Public Health Services DOC.

5. Communications – Public Health Services DOC:

Kaiser 3

Average: 2.73

Comments: BHH - Seemed to run off the timeline. KVH - One phone call made. CSV - We found that we need to identify our sites by saying, “this is Clinica Sierra Vista, East Bakersfield Community Health Center” because PHS didn’t know which clinics are CSV clinics. GSH - had some difficulty reaching by phone. TVHD - Unable to get information from CDPH by telephone or email. Glenwood

- Never received call from the DOC requesting updates. BMH - Communication to DOC was good. However, we never heard back on status of requests.

0 0.5 1 1.5 2 2.5 3 3.5 4 DOC Comm DOC Comm Observations 5.1: Strengths:

Communications were established with all but one HCF (Tehachapi Hospital). Overall, this was ranked very high in performance.

CAHAN was used successfully for Public Health DOC to Hospital Command Center communications.

Med-9 radio in the DOC failed to work properly; it was necessary to send EMS staff to a radio on the 2nd floor to manage radio communications on Med-9.

Med-9 had excessive background noise. Not all HCFs have Med-9 access.

Some HCFs reported difficulty reaching the DOC by telephone. No feedback from the DOC on status of resource requests. ReddiNet failed due to server overload statewide.

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Analysis: The DOC does not have sufficient radios or telephones to manage communications for this type of incident. The DOC was not staffed adequately to appropriately manage communications from the 11 Hospital Command Centers, 2 Clinic Command Centers, and 3 SNF Command Centers involved with this exercise.

The Public Health Services DOC is in the process of a comprehensive redesign and relocation which should help to resolve the radio and telephone issues. The decision to relocate staff for Med-9 communications was highly appropriate. Kern Mutual Aid is an alternative countywide radio communications channel that could be used for access to HCFs.

ReddiNet, a hospital status and messaging application used in several areas of the State, failed due to server overload. CAHAN was used by 2 hospitals and the Public Health DOC as an alternative for communications.

Recommendations:

1. Continue the redesign and relocation of the Public Health Services DOC to include adequate radio and telephone communications capacity and staffing.

2. Issue regular situation status updates and resource status updates from the Public Health Services DOC.

3. Expand the use of CAHAN, including further role definitions and an increased number of users of HCFs.

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HCF Capability 6: Communications – On-Scene Fire, Law, Ambulance

(with facility staff)

Capability Summary: Evaluate the healthcare facility (HCF) ability to communicate with on-scene fire department, law enforcement and ambulance personnel.

6. Communications – On-Scene Fire, Law, Ambulance (with facility staff):

KMC 4 SJH 4 BHH 4 BMH 4 Mercy 3 Mercy SW 3 GSH N/A RRH 0 TVHD N/A KVH N/A

Golden Living Center SNF N/A

Glenwood Gardens SNF N/A

Kaiser N/A

Average: 3.14

Comments: SJH - Many showed up, all played great. BHH - KCFD was very helpful. BMH - BFD response only. Communication onsite was very good. HCC and BFD were able to stay in constant communication via 2-way radios.

0 0.5 1 1.5 2 2.5 3 3.5 4 On-Scene Comm On-Scene Comm Observations 6.1: Strengths:

This was the highest ranked capability overall (although law and fire were not sent to all HCFs).

Areas for Improvement: None noted.

References:N/A

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HCF Capability 7: Facility Staff use of Personal Protective Equipment

Capability Summary: Evaluate the healthcare facility (HCF) staff ability to effectively choose and don appropriate PPE.

7. Facility Staff use of Personal Protective Equipment:

KMC 3 SJH 3 BHH 3 BMH 4 Mercy 1 Mercy SW 0 GSH N/A RRH N/A TVHD 2 KVH N/A

Kaiser N/A

Average: 2.29

Comments: SJH -Need to get PPE supplies to triage quicker. BMH - Excellent

0 0.5 1 1.5 2 2.5 3 3.5 4 PPE PPE Observations 7.1: Strengths:

For those HCFs that had simulated explosions and cyanide dispersal warranting PPE deployment (6 HCFs), 4 noted good to excellent results.

Areas for Improvement: None noted for systemic action.

References:N/A

Analysis: With little exception, this capability was ranked very high. No details were available with the lower rankings of Mercy and Mercy Southwest.

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HCF Capability 8: Hot Zone Establishment/Containment:

Capability Summary: Evaluate the healthcare facility (HCF) ability to establish and maintain a hot zone.

8. Hot Zone Establishment/Containment:

KMC 2 SJH 4 BHH 2 BMH 3 Mercy 1 Mercy SW 1 GSH N/A RRH N/A TVHD N/A KVH N/A

Kaiser 3

Average: 2.38

Comments: BMH - Good. Containment was only mocked. Kaiser - Staff contained area and followed procedures. 0 0.5 1 1.5 2 2.5 3 3.5 4 Hot Zone Hot Zone Observations 8.1: Strengths:

This capability has a fair to good average ranking. No details of any problems noted.

References:N/A

Analysis: Of those HCFs that set hot zones, the rankings range from poor to excellent. No details are available to support the poor rankings by Mercy and Mercy Southwest.

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HCF Capability 9: HVAC Shut-Down

Capability Summary: Evaluate the healthcare facility (HCF) ability to immediately shut down HVAC systems to limit spread of a hazardous material.

9. HVAC Shut-Down:

KMC 1 SJH 4 BHH N/A BMH 4 Mercy 3 Mercy SW 0 GSH N/A RRH N/A TVHD N/A KVH N/A

Kaiser N/A

Average: 2.40

Comments: BHH - Our bomb detonated outside, no shut-down needed. BMH - Excellent. Assumed AHUs would have shut-down automatically when bomb went off because of tie to Fire Alarm system. Staff that participated was also educated that any fire alarm pull-station could have been activated, which also would have shut down the AHUs. Kaiser - Unable to conduct HVAC shut down.

0 0.5 1 1.5 2 2.5 3 3.5 4 HVAC Shut-Down HVAC Shut-Down Observations 9.1: Strengths:

Of the HCFs that conducted HVAC shut-down, this was ranked fairly high. No details available for lower rankings.

References:N/A

Analysis: SJH, BMH and Mercy rankings are good to excellent. No details about lower rankings of KMC and Mercy Southwest.

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HCF Capability 10: Triage

Capability Summary: Evaluate the healthcare facility (HCF) ability to effectively triage victims.

10. Triage:

Kaiser N/A

Average: 2.86

Comments: SJH - Need PPE quicker, need physicians. CSV - Sites role-played probable injuries, type of injuries expected, how they would handle them. BMH - Excellent. Had 19 BCC students participate as mock-victims. Triage tags were used and the process went very well. Kaiser - No triage needed. Bombs located without incident.

0 0.5 1 1.5 2 2.5 3 3.5 4 Triage Triage Observations 10.1: Strengths:

Of those HCFs with simulated victims, this capability was ranked very high.

References:N/A

Analysis: It appears that this capability ranked fairly strong with the exception of Mercy. No details provided of specific problems other than San Joaquin Hospital‟s note of needing PPE to triage faster and physicians needed.

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HCF Capability 11: Decontamination

Capability Summary: Evaluate the healthcare facility (HCF) ability to effectively conduct mass decontamination of victims.

11. Decontamination:

Kaiser N/A

Average: 2.29

Comments: KMC - Delay in hospital team arriving. SJH - Fire Department did awesome. BMH - Good. Realized we did not have supplies readily available to contain the mobile decon runoff. Kaiser

- No decontamination needed. 0 0.5 1 1.5 2 2.5 3 3.5 4 Decon Decon Observations 11.1: Strengths:

SJH, BHH and BMH all ranked good to excellent.

No supplies readily available to contain water run-off from decontamination. KMC notes a delay in hospital decontamination team arrival.

References:N/A

Analysis: Containment of water run-off from decontamination is an important point. Pools can be used for this purpose, but have limited capacity. Hand pumps and bladders to hold contaminated water could be a consideration to augment mass decontamination supplies and equipment issued to HCFs.

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HCF Capability 12: Surge Equipment Mobilization

Capability Summary: Evaluate the healthcare facility (HCF) ability to effectively mobilize and set-up mass casualty surge tents and cots.

12. Surge Equipment Mobilization:

KMC 3 SJH 4 BHH N/A BMH 4 Mercy 1 Mercy SW 1 GSH 1 RRH N/A TVHD N/A KVH N/A Delano District SNF 1

Kaiser N/A

Average: 2.14

Comments: CSV - At some point our sites need to do a “tent in-service” with staff in order to understand the logistics of setting up the surge tents. GSH - Trouble putting up tent. BMH - Excellent. Alternate Care Site was in a building so only PPE, Decon and cots were mobilized. Kaiser

- Not needed. 0 0.5 1 1.5 2 2.5 3 3.5 4 Surge Surge Observations 12.1: Strengths:

KMC, SJH, and BMH all ranked good to excellent.

Good Samaritan Hospital notes difficulty setting up the surge tent.

Clinica Sierra Vista also notes the need for staff training in surge tent set-up. No details available from Mercy or Mercy Southwest on specific problems.

References:N/A

Analysis: There is an on-going need to train staff in mass casualty surge tents and cots deployment and set-up. This training is being arranged through the Bakersfield College Fire Technology Program for all HCFs that have been issued surge tents and cots.

1. Provide on site surge tents and cots deployment set-up training on an on-going basis for HCFs.

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HCF Capability 13: Resource Ordering

Capability Summary: Evaluate the healthcare facility (HCF) ability to effectively order resources through the California Medical-Health Mutual Aid System.

13. Resource Ordering:

KMC 3 SJH 2 BHH 2 BMH 3 Mercy 2 Mercy SW 1 GSH N/A RRH N/A TVHD N/A KVH 2 Delano District SNF 2

Kaiser N/A

Average: 2.13 Comments: SJH - Need better organization.

0 0.5 1 1.5 2 2.5 3 3.5 4 Resource Orders Resource Orders Observations 13.1: Strengths:

6 HCFs issued resource requests to the Public Health Services DOC.

The Public Health Services DOC referred the requests to the Region 5 RDMHS.

A written situation report was not developed or issued to the Region 5 RDMHS. A written resource request was not developed or issued to the Region 5 RDMHS. An operational area medical-health resource request form does not exist.

References:N/A

Analysis: When faced with a highly complex and expanding series of incidents such as with this functional exercise, it is difficult to allocate staff to complete complex forms. However, the forms help to provide clarity regarding logistical details of resource

requests. Clearly, an operational area medical-health resource request form is needed.

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HCF Capability 14: ICS Organizing, Command and Control

Capability Summary: Evaluate the healthcare facility (HCF) ability to effectively organize under ICS, establish effective command, and an appropriate span of control.

14. ICS Organizing, Command and Control:

Kaiser 2

Average: 2.47

Comments: SJH - Need more education. KVH - Could use more administration participation. CSV

- Sites aware of which staff members are assigned to the various positions. We need to exercise this piece more in future drills using specific scenarios so the IC knows what she is expected to do, etc.

Glenwood - Management knew responsibilities of taking control. Kaiser - Need to work on organizing command center and communication within the command center. There is a lot going on and its gets very confusing in the room.

0 0.5 1 1.5 2 2.5 3 3.5 4 ICS Use ICS Use Observations 14.1: Strengths:

All ranked from fair to good.

More HCF administrative involvement. More training and exercises.

References:N/A

Analysis: HCF ICS organizing rarely occurs. So it can be a very difficult transition when ICS has to be used under emergency conditions. HCF executives typically don‟t have time to attend training or exercises. To be effective, ICS must be used regularly.

1. Provide regular ICS (HEICS) training.

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Summary of HCF Recommendations:

1. Continue the redesign and relocation of the Public Health Services DOC to include adequate radio and telephone communications capacity and staffing.

2. Issue regular situation status updates and resource status updates from the Public Health Services DOC.

3. Expand the use of CAHAN, including further role definitions and an increased number of users of HCFs.

4. Examine cost effective solutions for contaminated water containment.

5. Provide on site surge tents and cots deployment set-up training on an on-going basis for HCFs.

6. Develop and implement an operational area medical-health resource request form. 7. Provide regular ICS (HEICS) training.

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Public Health Services Department Operations Center (DOC)

Capability 1: ICS Organizing

Capability Summary: Evaluate the ability of the Public Health Services DOC to ICS organize and operate.

1. ICS Organizing:

Comments: 1. Need more staff. 2. More extensive training is needed for all staff in SEMS/NIMS/ICS, especially for those staff that will be filling in at the Command positions and those who fill Branch& Unit positions. 3. More staff members were needed to assist in accomplishing key actions in the DOC.

The DOC was ICS organized.

An Incident Action Plan was created.

DOC staff were not identified by vests.

More training of DOC staff is needed in SEMS/NIMS/ICS. Additional staff are needed for the DOC.

References:N/A

Analysis: ICS organizing and operations in a DOC environment are relatively rarely done by the Public Health Services Department. And the existing DOC facility is insufficient for centralized DOC functions. ICS position training would be helpful for staff that operate in DOC Command, Command Staff, Branch Director, or Group Supervisor positions.

1. Develop a maximal DOC staffing chart. 2. Assign DOC positions 3 deep.

3. Provide I-300 training for DOC Command, Command Staff, Branch Director, and Group Supervisor positions.

4. Provide I-400 training for DOC Command, Command Staff, Branch Director, and Group Supervisor positions.

5. Provide ICS position training for DOC Command, Command Staff, Branch Director, and Group Supervisor positions.

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DOC Capability 2: Situation Status Assessment

Capability Summary: Evaluate the ability of the Public Health Services DOC to conduct a comprehensive situation status assessment.

2. Situation Status Assessment:

Comments: 1. Good processes by DOC Command staff.

The DOC conducted a situation status assessment. An Incident Action Plan was created.

References:N/A

Analysis: A comprehensive and frequently updated situation status assessment is extremely important. In this case, the DOC was provided a beginning scenario to work with, followed by regular updates from HCFs that were scripted for the exercise by both radio and telephone. Since the UHF radio in the DOC was not working, radio reports were received and relayed to the DOC by telephone.

Recommendations: None

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DOC Capability 3: Resource Status Tracking

Capability Summary: Evaluate the ability of the Public Health Services DOC to conduct comprehensive management of resource requests and status tracking.

3. Resource Status Tracking:

Comments: 1. Better than in past exercises. 2. Resource request form (ICS 308) was not useful. A new Excel/Access data collection form should be developed to more succinctly capture/report resource requests and processing.

The DOC did receive and manage multiple resource requests.

The DOC did refer resource requests to the regional level for Cyanokits, physicians, RNs, and Ambulance Strike Teams.

The RDMHS (simulated) communicated the status of resource requests and estimated time of arrival back to the DOC.

ICS 308 (resource request form) was not effective.

Written resource requests were not submitted to the RDMHS.

A medical-health resource request form for use within the operational area is not in place.

The status of resource requests were not communicated back to the HCFs.

References:N/A

Analysis: This exercise included several resource requests communicated verbally from 6 HCFs to the DOC for Cyanokits, physicians with emergency experience and RNs with emergency experience. The DOC initially requested 5 ambulance strike teams; followed later by Cyanokits, physicians and RNs. The State (simulated) also offered up a mobile field hospital which was accepted by the DOC. Deployment of a mobile field hospital is somewhat questionable for 120 total patients that could be decontaminated, treated, and transported out of the affected area.

However, with all 6 acute care hospitals in greater Bakersfield with explosions and Cyanide dispersal, those HCF EDs would be closed for many days, weeks, and possibly even months for hazardous materials clean-up before the EDs could be reopened and operational. So a mobile field hospital, by the time it was set up and operational, could be an important resource to help meet day-to-day demands in the area.

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As this was the first time that the DOC managed multiple resource requests at this extent, it is apparent that the processes for medical-health resources requesting need to be more formalized.

1. A written medical-health resource order form should be developed and implemented for use within the operational area.

2. Resource requests to the region should be written.

3. The status of resource requests should be regularly communicated back by the DOC to the source that requested the resources.

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DOC Capability 4: Communications - Internal

Capability Summary: Evaluate the ability of the Public Health Services DOC to effectively communicate internally.

4. Communications – Internal:

Comments: 1. Speaker phone useful. 2. Having a designated call person (EMS staff) helped to filter the amount of information coming to the DOC for processing. The new Call Center will help funnel all calls to help reduce the volume of calls coming directly to the DOC. 3. Having EMS & EHSD staff in the DOC greatly improved communications between the divisions and improved information assimilation and decision making process. 4. The speaker phone in the DOC was helpful in keeping the group focused on incoming calls

The DOC adapted well to the radio failure in the DOC.

Use of the speaker phone helped to filter communications to the DOC and reduce noise.

Having EMS and EHSD staff in the DOC helped to improve communications between Public Health, EMS, and EHSD divisions.

Insufficient number of telephones in the DOC.

Insufficient number of internet connections in the DOC. The UHF radio was not working in the DOC.

References:N/A

Analysis: Although the DOC adapted well to the challenges, internal communications by the DOC were difficult because of the relative size of the DOC, limited staffing of the DOC, only 3 phones available and only 1 internet connection. Relocation of the DOC to the first floor education center is clearly indicated with a phone bank and possibly wireless internet connections for up to 45 staff.

1. Move the DOC to the first floor education center. 2. Provide a phone bank to cover all DOC staff positions. 3. Provide internet access for all DOC staff positions.

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DOC Capability 5: Communications - External

Capability Summary: Evaluate the ability of the Public Health Services DOC to effectively communicate externally.

5. Communications – External:

Comments: 1. Med-9 channel failed in DOC. 2. The Med 9 radio channel has a lot of background noise from the Hospital ED’s. May need to find another method of communicating with the radios? 3. Insufficient number of telephones in the DOC. 4. There were only two telephones for all DOC members; all persons operating in the DOC need their own telephone. The lack of telephones necessitated absences from the DOC to enable outgoing calls to be made. 5. Radio communications failure. 6. The Med Channel base radio in the DOC failed to operate properly on the day of the exercise. It was necessary to delegate radio communications to the second floor with messages conveyed by

telephone. 7. Computer/Internet communications failure. 8. ReddiNet, an Internet-based application software, was intended to be used as the primary means of sharing information between the DOC and hospital command centers. With the Statewide exercise occurring, there were too many users and the system could not handle all of the traffic. We were forced to use an alternative means of DOC to command center venue for communication.

The DOC adapted well to the radio failure in the DOC.

Hospital Command Centers, Clinic Command Centers reported good communications overall on Med-9 with the DOC.

CAHAN was used successfully for DOC to HCF communications.

Repair and test the DOC UHF radio.

Track the status of ReddiNet and capacity issues.

References:N/A

Analysis: External communications by the DOC were limited because of the UHF radio failure in the DOC. Therefore, situation status reports and updates via radio had to be relayed over a phone to the DOC. In addition, ReddiNet failed. ReddiNet staff reported it was primarily caused by too many simultaneous statewide users in the MCI

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module and ReddiNet messaging that overloaded their server resources and caused it to fail. ReddiNet claims that normalizing the data-base will correct the capacity issues. DOC staff were provided phone numbers to Hospital Command Centers, Clinic

Command Centers, and SNF Command Centers; but it is unknown if these numbers were used.

1. Repair and test UHF radio. 2. Track the status of ReddiNet.

3. Develop and maintain a list of phone numbers to Hospital Command Centers, Clinic Command Centers, and SNF Command Centers.

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DOC Capability 6: Incident Action Planning

Capability Summary: Evaluate the ability of the Public Health Services DOC to develop and implement an effective Incident Action Plan.

6. Incident Action Planning:

Comments: 1. Well organized process based on H1N1 response last year.

An Incident Action Plan (IAP) was created for the DOC

The IAP was displayed with a computer projector for all DOC staff to view.

Areas for Improvement: None known

References:N/A

Analysis: The Public Health Services DOC gained extensive experience with

development of formal Incident Action Plans (IAP) during the 2009 H1N1 response. The IAP was rapidly developed and displayed during the exercise.

Recommendations: None

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DOC Capability 7: Use of the Medical-Health Mutual Aid System

Capability Summary: Evaluate the ability of the Public Health Services DOC to effectively use the California Medical-Health Mutual Aid System.

7. Use of Medical Health Mutual Aid System:

Comments:

1. Needs more practice.

The Public Health Services DOC issued requests for ambulance strike teams, Cyanokits, physicians, and RNs to the RDMHS (simulated).

The RDMHS provided confirmation that the resources were responding and the estimated time of arrival.

Resources were not requested in writing.

Specific locations to respond the resources to were not specified.

References:N/A

Analysis: A written situation status report was not developed as part of this exercise and the State Medical-Health Resource Request Form was not used. In the initial first few hours of a response, resource requests would likely be verbal; unless staff are reasonably available to complete the forms. Since this exercise was for the first 3 hours of response, the process was not fully engaged.

1. Conduct training on SitRep and State Medical-Health Resource Request forms completion.

2. Conduct exercises on SitRep and State Medical-Health Resource Request forms completion and referral.

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DOC Capability 8: Command and Control

Capability Summary: Evaluate the ability of the Public Health Services DOC to manage command and effective span of control.

8. Command and Control:

Comments: 1. More staff needed to process information. 2. Vests need to be worn to clearly identify positions. 3. When DOC fully sets up for a response, Branch & Unit level staff need to be quickly identified and assigned to specific impacted organizations for better communications and tracking of requests in support of the DOC command staff. More space is needed for that. 4. EHS-Hazmat self-deployed without informing Health DOC. Training for this staff on

communications with DOC/deployment is needed. Note: This was part of the exercise design to auto-dispatch. 5. KMRC volunteers self-deployed after notification from the Coordinator. More training is needed for the Medical Reserve Corps volunteers on how to deploy. Note: This was part of the exercise design to auto-dispatch.

The DOC was ICS organized.

An Incident Action Plan was created and implemented.

DOC staff were not identified by vests.

There were not enough DOC staff to properly manage the demands of the exercise. The existing DOC does not have sufficient space, telephones or internet connections. There were no situation status or resource status displays.

References:N/A

Analysis: Although the span of control was appropriate for the level of staffing of the DOC, there were an insufficient number of staff to manage the DOC demands based on this exercise. Again, the space limitations of the existing DOC is the greatest obstacle to staffing the DOC based on demand and effective command and control.

1. Assign vests based on DOC functions.

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3. Develop a situation status display. 4. Develop a resource status display.