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2014 Phase III:
Tabletop Exercise
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The 2014 Statewide Medical and Health
Exercise is sponsored by:
• California Emergency Medical Services Authority
• California Department of Public Health
In collaboration with:
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California Hospital Association
California Association of Health Facilities
California Primary Care Association
Governor’s Office of Emergency Services
Response partners representing local health departments,
emergency medical services, public safety and healthcare
facilities
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Welcome and Introductions
 Introduction of Exercise
Planners and
Facilitators
 Introduction of
Participants, Subject
Matter Experts,
Department Officials
and Media
 Housekeeping Issues
 Agenda Review
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Exercise Purpose
To evaluate current response concepts, plans,
and capabilities related to a pediatric/medical
surge of patients from a contagious disease
outbreak in the local community.
The exercise will focus on the coordination of
medical surge capabilities among community
healthcare and response partners.
2014 Statewide Medical and Health
Exercise Target Capabilities
Operational Communications
(formerly Communications)
Public Health and Medical Surge
(formerly Medical Surge)
Operational Coordination and On-Site Incident
Management
(formerly Emergency Operations Center Management)
Public and Private Services and Resources
(formerly Volunteer Management and Donations)
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Exercise Customization
Yellow font color signifies the need for customization by
the organization/agency and can be deleted after
editing at the local level.
The tabletop exercise may be customized to include
discussion of Operational Area and discipline specific
issues, policies and procedures, new equipment or
training, and gaps in planning.
Some on the information on the following slides is
bulleted and the full description that can be read is in
the Situation Manual and the Instructor Notes under
the slides.
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Tabletop Exercise Objectives
Capability: Operational Communication
(Formerly Communications)
1. Assess the communications process internally
and externally, based on local policies and
procedures.
2. Review redundant communication modalities
within and across response partners.
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Tabletop Exercise Objectives
Capability: Public Health and Medical Surge
(Formerly Medical Surge)
3. Determine strengths and weaknesses in
activation of medical and health partner’s
surge plans, focusing on pediatric populations.
Identify critical issues and potential solutions.
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Tabletop Exercise Objectives
Capabilities: Operational Coordination and On-Site
Incident Management
(Formerly Emergency Operations Center Management)
4. Identify the process to activate the Incident
Command System in response to an emerging
infectious disease. Determine specific levels
necessary based on scenario and local policies and
procedures.
5. Identify the steps in developing an Incident Action
Plan and conducting associated briefings. Medical
and Health partners provide situation information as
requested by the MHOAC Program for situation
reporting.
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Tabletop Exercise Objectives
Capabilities: Operational Coordination and On-Site
Incident Management
(Formerly Emergency Operations Center Management)
6. Identify the processes for medical and health
partners to provide current situational
information to the MHOAC program.
7. Examine the MHOAC program’s process to
develop and submit Medical Health Situation
Reports consistent with the EOM.
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Tabletop Exercise Objectives
Capability: Public and Private Services and
Resources
(Formerly Volunteer Management and Donations)
8. Identify the process for medical and health
partners across the response system to request,
distribute, track, and return medical
countermeasure resources, including scarce
resources, consistent with the EOM.
9. Validate the processes in place to activate the
local disaster medical volunteer system.
Resources to assist with
Exercise Customization
Response specific information and guidance may be
accessed through subject matter experts including, but
not limited to:
 Neonatal and Pediatric Subject Matter Experts
 Medical and Health Operational Area Coordinator
Program
 Mutual aid coordinators for medical, health, law
enforcement and fire services
 Communication partners
(Include those resources for your exercise on this slide)
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Options for Exercise
Customization
Examples of Customization Include:
 Address how your community adapts to a
sudden need for medical care and
hospitalization among a pediatric population
 Address how your local health department
would coordinate resource needs among the
healthcare response community at large
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Exercise Ground Rules
 Do not fight the scenario
 Assume the scenario is
real and may impact the
jurisdiction and the
participants
 Participate in a collegial
manner: share policies,
plans and practices that
may benefit others
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Exercise Ground Rules
 Be respectful: allow others
to speak and finish their
statements
 Follow communications
etiquette: turn off cell
phones, smart phones,
computers and any other
electronic data equipment
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Neonatal/Pediatric Needs
The following five slides are for background
information and are optional.
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Who is the Pediatric Patient?
• Neonate: 0-30 days old
• Infant: 30 day-12 months old
• Toddler: 1-4 years old
• Pediatric patient: < 15 years of age
California’s Pediatric
Population
 Males: 4,725,198 (2012)
 Females: 4,515,021 (2012)
 356,000 reside in single parent homes
 309,000 live with a grandparent(s)
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Pediatric Disaster
Considerations
Consider the unique needs of newborns, NICU
patients, and all pediatrics in disaster planning
 Challenges in airborne isolation
 Medication and vaccine availability for pediatrics
and dosing requirements
 Appropriate pediatric nutrition
 Daily pediatric supplies of diapers and bottles
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Pediatric Disaster
Considerations
 Compile a list of experts in pediatric infectious
disease care for Command Center resource
 Pediatric movement between tertiary centers
and basic facilities for best utilization of
pediatric resources and pediatric patient
movement issues
 Children may present unidentified and without
a parent or legal guardian
 How will you identify and reunite them?
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Pediatric Disaster
Considerations
 Consider environment of care issues related to age
 Safety hazards such as uncovered electrical outlets
 When possible, keep parents or legal guardians
with children
 Challenge in physician admitting privileges for
children 14 and under (malpractice issue)
 Child life support/behavioral health resources and
needs for children
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MERS-CoV Background
The following five slides are for background
information and are optional.
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Background – MERS-CoV
Definition: a viral respiratory illness, caused by a
new coronavirus called “Middle East Respiratory
Syndrome Coronavirus” (MERS-CoV)
• First reported in Saudi Arabia in 2012
• As of 5/2/14, there are 189 confirmed cases
and 82 deaths
• Coronaviruses are common viruses causing
upper respiratory tract infections in humans and
animals
• SARS is a well-known coronavirus
• First MERS-CoV case reported in the United
States 4/24/14
Background – MERS-CoV
Symptoms: severe acute respiratory illness with
symptoms of fever, cough, and shortness of breath
• About 50% mortality
• Some cases have mild respiratory illness
Transmission: between people in close contact.
• Positive transmission from infected patients to
healthcare personnel
• Clusters of cases in several countries are being
investigated
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Background – MERS-CoV
Source: not certain, likely from animal source
• Camels and a bat have tested positive
Diagnosis: PCR testing available at state public
health labs and CDC
• Respiratory tract specimens, stool
• Serology available at CDC
Treatment: Supportive care; no specific treatment
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Case Definition
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 Fever (>38C or 100.4F) and pneumonia or acute respiratory
distress syndrome; and either
 Fever (≥38oC, 100.4oF) and pneumonia or acute respiratory
distress syndrome; and either
 History of travel from countries in or near the Arabian
Peninsula within 14 days before symptom onset; or
 Close contact with symptomatic traveler with fever and acute
respiratory illness (not necessarily pneumonia) within 14 days
after travel from countries in/near Arabian Peninsula; or
 Member of a cluster of patients with severe acute respiratory
illness (e.g. fever and pneumonia requiring hospitalization) of
unknown etiology in which MERS-CoV is being evaluated
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Case Definition - Confirmed/Probable
Confirmed Case – A person with lab confirmation*
of MERS-CoV infection
Probable Case - A patient under investigation with
absent or inconclusive lab results for MERS-CoV
infection who is a close contact of a lab-confirmed
MERS-CoV case
*Lab confirmation requires a positive PCR on at
least two specific genomic targets or a single
positive target with sequencing on a second
http://www.cdc.gov/coronavirus/mers/case-def.html
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Tabletop Exercise
The exercise consists of 3 modules plus an
addendum for planning the November 20, 2014
Functional Exercise
 Each module will identify key issues followed by
questions for discussion
 Participants are encouraged to share their plans,
policies, strengths and gaps as identified in the
Organizational Self Assessments
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Tabletop Modules
 Module 1: Operational Communication and
Pediatric Medical Surge
 Module 2: Operational Coordination and
On-Site Incident Management
 Module 3: Public and Private Services and
Resources
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Scenario
November 2014: Influenza season has begun.
Hospital emergency departments and primary
care providers throughout (Organizations/
Jurisdiction can fill in location) are seeing an
increase in the number of influenza-like illness
(ILI) cases.
A family of 5 presents to the busy emergency
department (ED) with symptoms of influenza-like
illness (ILI)
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Family Members
 Dad reports 5 days of fever, cough and
shortness of breath. Mom and three kids
report 2 days of similar symptoms.
The full description can be read from the Instructor Notes in the slides
or from the Situation Manual.
 The 3 year old’s chest x-ray shows
pneumonia; he is hospitalized, receives
antibiotics and fluids and is discharged home
the next morning
 The others are instructed on supportive care
and discharged
Module 1:
Operational Communication and
Pediatric Medical Surge
Key Issues:
 Internal and external communication between key
response partners
 Use of redundant communication modalities
 How do you plan for an influx of pediatric patients?
What can healthcare partners not serving pediatric
populations do to assist with medical surge from
other facilities?
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Questions for Discussion
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(Jurisdictions can edit which questions they want to include)
1. What is your process for receiving and disseminating
critical information internally and externally with
government and non-government partners?
2. What redundant communication systems are in place
in case of system overload or failure and how are
they tested?
3. How do you provide situation information as
requested by the MHOAC Program for situation
reporting?
4. What format and process is used from the California
Public Health and Medical Emergency Operations
Manual in submitting your situation reports to the
MHOAC Program?
Questions for Discussion
5. How does your organization/jurisdiction
participate in a Joint Information System?
6. How would you share your organization’s
information with the Joint Information System?
Who approves information to be shared?
7. How does your organization/agency use social
media to disseminate information?
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Questions for Discussion
8. How do you plan for, and respond to, an influx of
pediatric patients during a medical surge? What
specific needs have you identified for pediatric
surge events?
(Staff/Equipment/Supplies/Medications, etc.)
9. How do non-pediatric acute care facilities
respond to pediatric surge when pediatric
specialty receiving centers are either
overwhelmed or unavailable?
10. How do healthcare facilities that do not serve
pediatric populations, such as some long-term
care facilities, assist the community’s and
healthcare partner’s surge needs?
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Module 1
Discussion Report Back
Scenario (continued)
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 Two days later, the family presents to another ED
with worsening symptoms and developing
pneumonias
 The father is admitted with pneumonia
 The 3 year old is again admitted, this time to ICU
and is intubated
 The Father’s history reveals travel to Dubai with 15
businessmen from California 10 days before onset
of symptoms, and on to Germany for 2 days then
home.
Scenario (continued)
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 Due to the dad’s symptoms and travel his physician
notifies the local health department and collects
specimens for Middle East Respiratory Syndrome –
Coronavirus (MERS – CoV) in addition to routine
respiratory pathogens
 The local health department initiates contact tracing
and identifies several sites where the family has
had close contact with others
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Module 2: Operational Coordination
and On-Site Incident Management
Key Issues:
 Response is coordinated through the use of Incident
Command System principles and Command
Centers/Emergency Operations Centers
 Incident Action Plans are developed to guide and
document the response and recovery phases
 Provide situation reporting as requested by the
MHOAC Program utilizing the California Public Health
and Medical Emergency Operations Manual format and
process
Questions for Discussion
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(Jurisdictions can edit which questions they want to include)
1. How does your organization/jurisdiction implement
Incident Command System principles to organize and
guide response and recovery operations in an
emergency? Does the use of Incident Command
System principles address, when necessary, the
application of unified command?
2. How is your Command Center/Emergency
Operations Center activated to support Incident
Command System operations? Does the activation
process utilize a written plan?
Questions for Discussion
3. How are key partners notified of activation? What
time frame is the notification communicated in?
4. How does your organization/jurisdiction
communicate and share information with other
members of the incident management team or
Command Center/Emergency Operations Center
personnel? Is there a policy and procedure that
covers this? If procedures are in place, is the
process regularly tested?
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Questions for Discussion
5. What action planning procedures and forms are
used to document and guide the response and
recovery process? Is the Incident Action Plan
shared with response partners in the jurisdiction?
6. How are requests made or responded to for
situational reporting utilizing the California Public
Health and Medical Emergency Operations
Manual?
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Questions for Discussion
7. What is the operational area plan during a
pediatric medical surge? How does the plan
address mutual aid? How does the plan
coordinate from the operational area to the
regional level to the State level?
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Module 2
Discussion Report Back
Scenario (continued)
Emergency Departments and
community health centers are
seeing a definite rise in
numbers of influenza-like
illness (ILI) cases and
admissions have increased
over 10% with acute
respiratory illnesses, including
a large influx of pediatric
patients ages 2-16 years
(Organizations/ Jurisdictions can
fill in number or change the
percentage to meet exercise
testing needs for the area)
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Scenario (continued)
 Two days later, CDPH and
CDC labs confirm MERSCoV in all members of the
family and multiple contacts
 With MERS-CoV
confirmation, high mortality
in other countries, and
intense media coverage,
people with ILI are flooding
the healthcare system
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Scenario (continued)
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 The local health department sends out a Health
Alert/Advisory to notify students, teachers and
employees of the possible exposure and instruct
them to seek medical care if they have ILI
symptoms
 The local health department identifies and contacts
those with close contact/exposure
 Many close contacts have ILI symptoms and are
tested for MERS-CoV; >50% of the contacts tested
are positive and many have been hospitalized
Module 3: Public and Private
Services and Resources
Key Issues:
 Identifying needs in a pediatric surge event
 Requesting, distributing, tracking and
returning materials and medical
countermeasure resources
 Activating local disaster medical volunteer
systems
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Questions for Discussion
(Jurisdictions can edit which questions they want to include)
1. How do you identify your human and material
needs in a pediatric surge event?
2. How do you request, distribute, track and return
medical countermeasure resources in
accordance with the EOM, to include allocation
of scarce resources?
3. What mutual aid agreements are in place?
4. How is the local disaster medical volunteer
system activated? What are the triggers to
activating the system?
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Module 3
Discussion Report Back
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Conclusion of
Discussion-Based Tabletop
Planning for the November
Functional Exercise
The scenario will be focused
on a pediatric medical surge.
Customization of the exercise
allows incorporating other
objectives as needed.
Examples for customization
include issues identified in
past exercises, new training
or equipment, or new policies
and procedures.
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Planning for the November
Functional Exercise
Note: Not all organizations and/or agencies will use the
scenario of a pediatric medical surge due to an emerging
infectious disease as the basis for the November 20,
2014, Functional Exercise.
This exercise was designed to assist the PHEP/CRI
Point-of-Distribution Exercise and some jurisdictions may
use Anthrax as the agent, but the option of an infectious
disease was chosen to assist with meeting Community/
Agency/Organization Hazard Vulnerability Assessment
(HVA) exercise requirements.
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November Exercise
Issues for Discussion
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Exercise Level of Play:
 What level of exercise play do the organizations/
agencies represented today anticipate for the
November 20, 2014 exercise?
 Examples include communications drill, functional and
full scale exercises. Level of play may include use of
simulated patients, movement of patients to healthcare
facilities, provision of mutual aid, etc.
 Will your organization/agency activate its Command
Center/Emergency Operations Center?
Issues for Discussion
Exercise Times/Duration:
Exercise play is being developed
to include a message to begin
the exercise.
Participants may begin exercise
play at their discretion but are
strongly encouraged to
collaborate with local/operational
area partners
Can participants estimate their
hours of exercise play at this
time?
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Issues for Discussion
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Exercise Customization:
 Discuss organization/agency impacts from a pediatric
medical surge not only on specialty receiving centers
but all healthcare entities, including long term care
acceptance of adult patients to increase bed
availability at acute care facilities
 Ensure local area exercise customization is included
in the Master Scenario Events List
 Consider including additional Local Public Health
Annex objectives and Master Scenario Events List
(MSEL)
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Issues for Discussion
Testing of Policy and Procedures:
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Are there any plans, policies or procedures which
individual departments or organizations/agencies
would like to test? Examples include: infectious
disease plans, pediatric surge, continuity of
operations plans, etc.
Identify the plans to be tested that should be
included in customization of the Master Scenario
Events List
Role of State Agencies
On November 20, 2014, the California Department of
Public Health and the California Emergency Medical
Services Authority will open the Medical and Health
Coordination Center (formerly the Joint Emergency
Operations Center).
The Governor’s Office of Emergency Services is
anticipated to participate along with the Regional
Emergency Operations Centers to support local and
regional exercise play.
This will provide the opportunity for local participants
to request additional resources, submit and receive
situation status reports and respond to California
Health Alert Network (or other notification systems)
messages and receive further direction.
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Thank You
For Your Participation
Additional materials may be found on:
California Statewide Medical and Health
Training and Exercise Program website:
www.californiamedicalhealthexercise.com
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