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2013 Phase III:
Tabletop Exercise
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The 2013 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
California Emergency Management
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 medical surge of
patients from a foodborne illness outbreak in the
local community.
The exercise will focus on the coordination of
surveillance activities and health system
capabilities anticipated when managing a medical
surge among community healthcare partners.
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2013 Statewide Medical and Health
Exercise Target Capabilities
 Emergency Operations Center Management
 Medical Surge
 Communications
 Emergency Public Information and Warning
 Public Health Epidemiological Surveillance
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Tabletop Exercise Objectives
Exercise Planners may insert organization/agency
specific objectives found in the Situation Manual
beginning on page 3, may customize objectives
consistent with the tabletop exercise questions
or may delete this slide. The following slides
can be edited according to the objectives used.
(Yellow font color signifies the need for
customization by the organization/agency)
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Tabletop Exercise Objectives
1. Evaluate the ability to utilize redundant
communication modalities and processes
internally and externally per policies and
procedures within the exercise timeframe.
2. Evaluate the ability of medical and health
partners to activate surge plans within
established protocols.
3. Evaluate the ability of medical and health
partners to participate in the California
Statewide HAvBED poll within one hour of the
initial notification.
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Tabletop Exercise Objectives
4. Evaluate the ability of medical and health
partners to utilize California Public Health and
Medical Emergency Operations Manual (EOM)
format and/or local situation status reporting
format to exchange and share event situational
intelligence/awareness within the exercise
timeframe.
5. Evaluate the ability to implement the Incident
Command System (ICS) in response to a
foodborne illness.
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Tabletop Exercise Objectives
6. Evaluate the ability of medical and health partners to
develop an Operational Period Action Plan (AP) and
conduct associated briefings.
7. Evaluate the ability of medical and health partners to
request, distribute, track, and return resources in
accordance with the California Public Health and
Medical Emergency Operations Manual (EOM), to
include allocation of scarce resources.
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Tabletop Exercise Objectives
8. Evaluate the ability of medical and health partners to
validate and coordinate risk communication between
command centers/operations centers and partners during
exercise play (i.e., Emergency Operations Center, Nursing
Home Command Center, Hospital Command Center,
Department Operations Center).
9. Evaluate the ability of medical and health partners to issue
public information, alerts, warnings, and notifications
through established systems to patients, staff, the public,
coordinating officials, incident managers and responders
quickly and effectively.
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Tabletop Exercise Objectives
10. Evaluate the ability of local Public Health Departments to
conduct surveillance and subsequent epidemiological
investigations to identify potential exposure and disease.
11. In response to a notification of an existing threat of food
contamination, evaluate the ability to implement necessary
control measures to stop further cases of illness or disease
in accordance with established policies.
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Exercise Customization
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.
(This slide can be deleted once
customization is done)
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Exercise Customization
Response specific information and guidance may
be accessed through subject matter experts
including:
 Public Health and communicable disease experts
 Medical and Health Operational Area Coordinator
 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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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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Foodborne Illness Statistics
Each year in U.S. foodborne
diseases cause:
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9.4 million cases

55,961 hospitalizations

1,351 deaths
(Emerging Infectious Diseases. Volume
17, Number 1. January 2011)
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Background
What foodborne disease do these foods have
in common?
 Raw sprouts
 Pizza
 Cookie dough
 Fresh spinach
 Ground beef patties
 Romaine lettuce
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Background
Shiga Toxin producing E. coli:
 Gram negative bacteria
 Considered normal flora in intestines
 The incubation period is usually 3-4 days after the
exposure, but may be as short as 1 day or as long
as 10 days
 Diarrhea (often bloody) and abdominal cramps
 Little or no fever (less than 101 degrees Fahrenheit)
Impact of E. coli Outbreaks
A large outbreak of Shiga Toxin-producing E. coli
infections linked to sprouts occurred in Europe in
2011, resulting in 3,950 cases.
 53 deaths (51 in Germany)
 852 confirmed cases of hemolytic uremic syndrome
(HUS) a type of kidney failure
 Cases were reported in Germany, Switzerland,
Poland, the Netherlands, Sweden, Denmark, UK,
Canada and the USA
http://www.cdc.gov/ecoli/2011/ecoliO104/index.html
European Food Safety Authority
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Impact of Recent E. coli Outbreak
Multistate Outbreak of Shiga Toxinproducing E. coli:
A total of 33 persons infected with Shiga Toxin
producing E. coli were reported from five states
 46% of ill persons were hospitalized. Two ill persons
developed hemolytic uremic syndrome (HUS), a
type of kidney failure, and no deaths were reported
 Traceback investigations of pre-packaged leafy
greens purchased by ill persons
http://www.cdc.gov/ecoli/2012/O157H7-11-12/index.html
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Impact of Recent E. coli Outbreak
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Multistate outbreak of E. coli infections linked to ground
beef patties:
 Several state health departments, CDC, and the
United States Department of Agriculture’s Food Safety
and Inspection Service investigated a multi-state
outbreak of E. coli infections. As a result, a recall of
21.7 million pounds of frozen ground beef patties was
issued.
 Health officials found many ill persons had consumed
the same brand of frozen ground beef patties. Opened
and unopened packages of patties recovered from
patients' homes yielded E. coli.
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Tabletop Exercise
 The exercise consists of four modules plus an
addendum for planning the November 21, 2013
Functional Exercise.
 Each module will identify the 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.
Scenario
On November 18, 2013, health care providers at
community health centers, private physician’s offices
and local emergency departments began seeing
previously healthy patients with complaints of
abdominal pain throughout
(Organizations/Jurisdiction can fill in location)
County.
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Scenario (Continued)
Within one day cases of bloody diarrhea had been
reported by (Organizations/Jurisdictions can fill in
number) health care providers at community health
centers, private physician’s offices and local emergency
departments in the county. Two days after the first
reports of abdominal pain and bloody diarrhea,
(Organizations/Jurisdictions can fill in number) patients
were admitted to the Intensive Care Unit with symptoms
of decreased urine output, lethargy and persistent bloody
diarrhea.
(Organizations/Jurisdictions can fill in number)
patients were diagnosed with hemolytic uremic
syndrome. Cases presenting similar symptoms continue
to be reported throughout the county.
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Scenario (Continued)
Five days after the first
reported case,
(Organizations/Jurisdictions
can fill in number) patients
have been identified with
similar presenting symptoms
at local hospitals, community
health centers and private
physician practices.
Module 1: Emergency Operations
Center Management and Medical
Surge
Key Issues:
 Response is coordinated through the use of Incident
Command System principles and Command
Centers/Emergency Operations Centers
 Action Plans are developed to guide and document
the response and recovery phases
 Activation of Surge Plans
 Request and/or response to resource requests
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Questions for Discussion
(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
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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?
How is information transfer validated? Is there a
policy and procedure that covers this? If procedures
are in place, is the process regularly tested?
Questions for Discussion
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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 do you plan for an influx of patients including the
access and functional needs population? What types
of services can be altered, postponed or relocated to
other sites? Have clinical providers been active in the
decision making for alteration of services?
Questions for Discussion
7. What is the operational area plan during a medical
surge, including the access and functional needs
population? How does the plan address mutual aid?
How does the plan coordinate from local to regional
to State level?
8. Which partner organizations can assist in providing
services that you must alter or suspend due to a
medical surge? Do you have Memoranda of
Understanding signed with these partner
organizations?
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Questions for Discussion
9. What is the operational area resource requesting
process? What is the operational area process to
request resources to the region or the State? Are
these processes regularly tested?
10. How do you request, respond to, distribute, track
and/or return resources in accordance with the
California Public Health and Medical Emergency
Operations Manual?
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Module 2: Communications and
Public Information and Warning
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Key Issues:
 Internal and external communication between key
response partners
 Use of redundant communication modalities
 Utilize California Public Health and Medical Emergency
Operations Manual and/or local situational
intelligence/awareness within the exercise timeframe
Questions for Discussion
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1. What is your role in receiving and disseminating
critical information internally and externally?
2. What mechanisms and/or technology are in place to
receive and disseminate information internally and
externally?
3. How does your organization/jurisdiction participate
in a Joint Information System?
4. How would you share your agency’s information
with the Joint Information System? Who approves
information to be shared?
Questions for Discussion
5. What is your plan to notify staff, patients, clients,
and/or stakeholders of a foodborne illness event?
What individuals or groups require notification?
What are the communication methods to
disseminate this information and the safety
measures to be taken during a medical surge due to
foodborne illness? How is communication
coordinated between Infection Preventionists,
Disaster Coordinators and the local health
department?
6. How does your organization/agency use social
media to disseminate information?
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Module 3: Emergency Public
Information and Warning
Key Issues:
 Risk communication messaging is developed
within the operational area Joint Information
System
 Policy and procedure for dissemination of key
messages is established within the
facility/agency/department
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Questions for Discussion
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1. How are public information and warning updates
coordinated with local, state, and federal agencies?
How does your organization/agency coordinate risk
communication between command
centers/operations centers, and partners during
medical surge? How does your organization/agency
handle conflicting guidance from different local, state
and federal agencies?
2. How are public information and warning updates
disseminated?
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Questions for Discussion
3. What is your risk communication plan for
media inquiries prior to an official press
release being issued? When does notification
go out to local health departments, health care
providers and the public?
4. How is risk communication addressed? What
modalities and redundant methods are used?
5. How does your organization/agency utilize
public hotlines to provide information?
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Scenario (Continued)
Laboratory staff have requested guidance from the
local health department on appropriate protocols for
specimen collection and laboratory techniques to
confirm the diagnosis.
Health care facilities are requesting guidance on
necessary levels of isolation and personal protective
equipment requirements for staff.
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Scenario (Continued)
Ambulance companies are reporting an increase in
call volume and extended delays in offloading patients
at local emergency departments. Hospitals are
experiencing continuing surge with increasing
emergency department wait times.
The initial epidemiologic investigation has not
revealed a consistent pattern of age, race,
occupation, geographic distribution or previous
symptomatology among patients which might indicate
a source of the offending agent.
Module 4: Public Health
Epidemiological Surveillance and
Investigation
Key Issues:
 Epidemiological surveillance and investigation
coordinated with the health care partners
 Implement control measures
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Questions for Discussion
1. Which state and local authorities would provide
information and guidance regarding the Shiga
Toxin-producing E. coli outbreak? Do you have
24/7 contact information for these authorities?
2. What actions would you take to communicate
with the public health authorities if a patient
presents with a suspected foodborne disease?
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Questions for Discussion
3. Beyond health care providers, who else does the
local health department communicate with if they
see an increase in certain disease syndromes?
4. When and how would your organization/agency
be made aware of an increase in Shiga Toxinproducing E. coli isolates within your jurisdiction?
Are there multiple modes of communication for
this kind of information?
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Questions for Discussion
5. What would prompt an investigation, and who would
undertake the investigation and analysis if an
outbreak were to occur in your jurisdiction?
6. How systematic is the collaboration between your
organization/agency and the laboratories to influence
prioritization of work? What rules or processes
govern this relationship?
7. How are control measures issued by public health?
How are the control measures issued by public
health implemented?
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Conclusion of
Discussion-Based Tabletop
Planning for the November
Functional Exercise
The scenario will be a medical
surge due to foodborne illness.
Customization of the exercise
allows incorporating other
objectives as needed.
Examples 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 medical surge due to foodborne
disease as the basis for the November 21, 2013,
Functional Exercise.
The provision of mutual aid to affected areas may be
used as the scenario to launch the actions and
activities undertaken during the exercise.
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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 21, 2013 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, activation of the joint information center,
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
Exercise Customization:
 Discuss organization/agency
impacts from a medical surge
due to foodborne disease
 Identify additional areas of
impact for epidemiological
surveillance
 Ensure exercise customization
is included in the Master
Scenario Events List
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Issues for Discussion
Exercise Customization (Continued)
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: utilities
management, patient surge, fatality response,
continuity of operations plans, etc.
Identify the plans to be tested that should be
included in the customization of the Master
Scenario Events List
Role of State Agencies
On November 21, 2013, 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 California Emergency Management Agency is
anticipated to participate by opening the State
Operations Center and 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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