State of California

2007 Statewide Medical & Health

Disaster Exercise

EXERCISE GUIDEBOOK
A collaboration of:
California Department of Public Health
Emergency Medical Services Authority
California Hospital Association

October 25, 2007

 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

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 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

Executive Summary
August 2007

Dear Exercise Participant:

With the new and emerging threat of outbreaks of infectious disease, such as pandemic influenza or biological
terrorism, which have the potential for causing mass casualties, healthcare providers and systems must be
prepared to respond to and recover from these catastrophic events.

Over the last year, surge capacity and capability planning has been a focus for hospitals, clinics, Emergency
Medical Services (EMS), local public health departments, other healthcare providers, and government officials at
the local, regional, state, and federal level. The 2007 Statewide Medical and Health Disaster Exercise has been
developed for hospitals, clinics, EMS and local public health departments to test and evaluate the surge plans using
a scenario of biological terrorism. A release of pneumonic plague would result in the surge of large numbers of
patients who would require care for extended periods. The scenario has been developed to encourage and allow
hospitals and health care providers to interact with local law enforcement, local emergency management and
community partners. Other features of the exercise focus on shift changes and incident action planning.

The 2007 exercise is structured for 12 hours, from 5:00 am to 5:00 pm, to facilitate the exercising of multiple shifts
(nights, days, and evenings) and to include shift changes, especially in the Hospital Command Center (formerly
known as the Hospital Emergency Operations Center). A 12 hour exercise may pose unique planning and logistical
issues for participants. Hospitals are not required to conduct a 12 hour exercise, but should consider the exercise
timeframes as “modules” which can be used to customize the exercise to the facility’s specific objectives.
Therefore, if a participant plans a four-hour exercise, the content of the exercise “modules” could be timed for your
exercise period. See page 2 for tips on how to use the guidebook.

We encourage the participants to coordinate with other community partners to conduct a community-wide exercise.
The Operational Area (OA) Exercise Contact is your point of contact for planning, questions, and organization for
the exercise. We encourage you to contact the OA Exercise Contact early in the planning process to assist you in
the execution of the 2007 exercise. Please see page 146 of this guidebook for the OA Exercise Contacts list.

Important Timelines and Deadlines

September 28, 2007 Deadline to fax Intent to Participate form (page 101) to the OA Medical/Health Exercise
Contact (see list of contacts on page 146).

October 25, 2007 The exercise is scheduled from 5:00 am to 5:00 pm. The scenario stages the threat of
exposure to occur on Monday, October 22, 2007, and the healthcare system responds to
the overwhelming numbers of patients presenting with symptoms. Hospitals may conduct
exercises for any number of hours during the exercise play.

November 9, 2007 Deadline to complete and mail the appropriate Master Answer Sheet for your discipline to
the address on the form to receive a certificate of participation.

Thank you for your commitment to disaster medical planning and preparedness.
We look forward to hearing about your successful exercise!
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

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 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

Table of Contents

Tips: How to Use the Guidebook .................................................................................................2

Exercise Objectives ......................................................................................................................7
Acute Care Facility/Hospital Objectives ....................................................................................7
Community Care Clinic/Medical Clinic Objectives.....................................................................9
Emergency Medical Services Providers/Ambulance Providers .................................................9
Local Public Health Departments ............................................................................................10
Operational Area Emergency Operations Center, Medical & Health Branch ..........................11
Exercise Scenario.......................................................................................................................12
Exercise Intelligence Messages .................................................................................................37
Master Sequence of Events Lists ...............................................................................................42
Acute Care/Hospital Facilities .................................................................................................43
Community Clinics ..................................................................................................................61
EMS/Ambulance Providers .....................................................................................................71
Local Public Health Departments ............................................................................................80
Conducting the Exercise.............................................................................................................93
Exercise Planning Assumptions ..............................................................................................94
Pre-Exercise Activities ............................................................................................................95
Exercise Day Activities............................................................................................................96
Tips for Hospitals ....................................................................................................................98
Reporting Intent to Participate ..................................................................................................100
Sample Press Release .............................................................................................................103
Evaluating the Exercise ............................................................................................................104
Exercise Evaluation Tools .....................................................................................................105
Acute Care/Hospital Facility Master Answer Sheet ...............................................................110
Community Clinic Master Answer Sheet ...............................................................................117
EMS/Ambulance Provider Master Answer Sheet ..................................................................122
Local Public Health Department Master Answer Sheet.........................................................127
Glossary and Acronyms............................................................................................................132
Plague FAQ ..............................................................................................................................142
Operational Area (OA) Exercise Contacts ................................................................................145
OES Mutual Aid Regions Map ..................................................................................................151
Acknowledgements...................................................................................................................151
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

Tips:
How to Use the Guidebook

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 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

Tips: How to Use the Guidebook

The 2007 Statewide Medical and Health Disaster Exercise Guidebook is intended to provide participants
with a scenario and tools to plan and conduct an exercise in their healthcare organization. The target
audience for this exercise is acute care hospitals, community care clinics, public and private emergency
medical services providers, and local health departments. Other healthcare system providers (e.g., long-
term care and other healthcare providers, auxiliary communications systems) are encouraged to participate
in the healthcare community exercise.

The Operational Area (OA) Emergency Operations Center (EOC) is encouraged to participate in the
exercise by activating the EOC Medical and Health Branch and providing coordination and allocation of
resources and information-sharing. The Regional and State Emergency Operations Centers will not be
participating in this year’s Statewide Medical and Health Disaster Exercise. The OA EOC and OA Exercise
Contact are encouraged to simulate important agencies (e.g., the Regional and/or State EOC, the Center
for Disease Control and Prevention, Poison Control Centers) to lend realism to the OA exercise.

The exercise is scheduled for October 25, 2007 from 5:00 am until 5:00 pm. The exercise was planned
for 12 hours to accomplish the following objectives:
• Exercise three shifts (am, pm, nights) by spanning the 12 hours
• Conduct a shift change for the incident management personnel in the organization
• Assess and plan for extended operations and address recovery issues
• Conduct incident action planning
• Provide the participant with exercise tools and options to maximize exercise play

Reporting Intent to Participate

Participants should report their intent to participate to the OA Exercise Contact no later than September 28,
2007 using the form on page 101. This year, there is no intent to participate summary report required from
the OA Exercise Contact to the Regional Disaster Medical and Health Specialist (RDMHS). The OA
Exercise Contact, however, is encouraged to communicate with the RDMHS about the OA participation in
the exercise.

Using the Exercise Scenario as “Modules”

The scenario is constructed to accommodate a 12 hour exercise and to introduce multiple challenges for
participants in the management of an outbreak of an infectious disease due to a terrorism event and
management of a surge of patients. It is recognized that participants may not be able to conduct a 12 hour
exercise; therefore, the exercise scenario was developed in modular format to be adapted for the
participant’s exercise goals and objectives.

Each timeframe in the scenario can be considered a “module”. Each of the timeframes highlight a specific
aspect of patient management, command and control, or surge management. For example: a participant
could chose multiple timeframes (e.g., 10-25-07 at 7:00 am, 10-25-07 at 11:30 am, and 10-25 at 2:00 pm)
as modules to exercise and meet the organizational exercise objectives. These modules would be
compiled into an exercise for the facility and can be re-timed to fit the scheduled exercise period.

Exercise Objectives
Exercise objectives are provided for acute care hospitals, community clinics, EMS providers, local public
health departments, and OA EOC Medical & Health Branches. While there are multiple objectives for
each, participants may use the objectives to exercise key components of the organization’s emergency
operations and surge plans, policies, and procedures or can exercise all objectives.

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Statewide Medical & Health Disaster Exercise
October 25, 2007

Pre-Exercise Intelligence Messages

Pre-event intelligence reports are included in the Guidebook to enhance the realism of the terrorism event
and to test internal communication systems. These messages are for exercise use only and are developed
to match the scenario for the Statewide Medical and Health Exercise.

To test the communication of intelligence information to healthcare providers, the two intelligence
messages contained in the Guidebook will be distributed to participants before and during the exercise.
The exercise intelligence messages can be found on page 37.

Message One: Monday, October 22, 2007 at approximately 4:30 pm:

The first intelligence message containing information about a possible threat will be broadcast to
medical and health providers from:
• The Emergency Medical Services Authority (EMSA) to Local Emergency Medical
Services Agencies (LEMSA) and EMS providers via email
• The California Department of Public Health (CDPH) to local public health departments
via the California Health Alert Network (CAHAN)
• The California Hospital Association (CHA) to hospitals via email and fax
• The California Primary Care Association (CPCA) to the community clinics via email

Message Two: Wednesday, October 24, 2007 at approximately 9:00 am:

The second message is a higher alert than message one, and alerts healthcare providers of an
impending threat. The message will be disseminated to medical and health providers as described
above.

The purpose of the messages is to exercise communication of intelligence information to healthcare

providers and for healthcare providers to test internal policies and procedures to manage sensitive
information within the organization, including to whom the information is given and what measures are
implemented due to the threats. Should the message not reach the participant during the exercise, the
participant can use the messages provided in the Guidebook (page 37).

Background for the Scenario

The exercise begins on Thursday, October 25, 2007 at 5:00 am, but scenario background is provided to
“set the stage” for the events leading up to the day of the exercise. The simulated background events
begin on Monday, October 22, 2007 with the Federal Department of Homeland Security notifying the State
of California Office of Homeland Security of threats to the medical and health system (pre-exercise
intelligence message one). The exposure event occurs on October 23rd and on October 24th the second
pre-exercise intelligence message is released (see above).

Some of the background information for the scenario should be used by the exercise planner or controller
to plan and conduct the exercise, but this information should not be shared with internal participants.
Exercise planners can inject the intelligence information, but keep the event intelligence and release of the
agent out of the internal exercise play until identified in the scenario by officials.

Master Sequence of Events List

This year, the guidebook contains a master sequence of events list (MSEL) to assist participants in
conducting the exercise. The MSEL consists of the discussion and action points embedded in the
scenario, listed by participant category. Participants can expand the MSEL by developing exercise
injects and messages, customized to stimulate organizational play.

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 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

Exercise Evaluation
Evaluating the exercise and creating an after-action report (AAR) and corrective action plan (CAP) can
pose a challenge to planners. The Guidebook contains resources and references for exercise evaluation
tools to assist the organization’s exercise planner.

Participant Recognition and Certificates of Participation

After the exercise, Certificates of Participation will be issued to all exercise participants that complete and
submit the Exercise Evaluation Master Answer Sheet (starting on page 111) to the address below. The
deadline to submit the Exercise Evaluation Master Answer Sheet form is November 9, 2007.

Exercise Master Answer Sheets should be mailed to:

Emergency Medical Services Authority

1930 9th Street
Sacramento, CA 95814
Attn: Statewide Exercise Evaluation

Upon receipt of the Exercise Evaluation Master Answer Sheet, the exercise contractor will mail the
Certificate of Participation to the organization. Certificates will be issued no later than December 1,
2007.

Auxiliary Communications Systems

This exercise does not include the activation of Auxiliary Communications Systems (ACS) because the
focus is on participant surge planning. Participants may elect to exercise ACS during this exercise and
develop injects or add to the scenario.

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Statewide Medical & Health Disaster Exercise
October 25, 2007

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Statewide Medical & Health Disaster Exercise
October 25, 2007

Exercise Objectives

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 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

EXERCISE OBJECTIVES

Acute Care Facility/Hospital Objectives

Objective I: Pre-Exercise Event:
Assess the facility’s integration and participation in community-wide emergency preparedness,
planning and response. This integration includes area hospitals, community clinics, public
health, other healthcare organizations (e.g., long-term care), public and private emergency
medical services (EMS) providers, law enforcement, and emergency managers. As a result of
this assessment, collaborate and build relationships with important providers to prepare for the
exercise and any actual event.
Joint Commission 2007 Standards: E.C.4.10.2, E.C.4.10.3, E.C.4.10.5, E.C.4.10.6, E.C.4.20.1, E.C.4.20.2,
E.C.4.20.3
Joint Commission 2008 Standards: E.C.4.11.3, E.C.4.11.4, E.C.4.11.6, E.C.4.11.7, E.C.4.12.1, E.C.4.12.2, E.C.
4.20.1, E.C.4.20.2, E.C.4.20.4

Objective II:
Activate the Emergency Operations Plan and the incident command system (e.g., the Hospital
Incident Command System [HICS]) to manage the biological surge event and large influx of
patients.
Joint Commission 2007 Standards: E.C.4.10.2, E.C.4.10.3, E.C.4.10.6, E.C.4.10.8, E.C.4.10.19, 4.10.21
Joint Commission 2008 Standards: E.C. 4.12.1, E.C.4.12.2, E.C.4.12.3, E.C.4.12.4, E.C.4.12.5, E.C.4.15.4
NIMS Implementation Activity for Hospitals and Healthcare Systems: Element 1 and 2

Objective III:
Exercise facility surge plans to expand capacity and manage a large influx of patients, including
the activation of hospital-based alternate care sites.
Joint Commission 2007 Standards: E.C.4.10.10, E.C.4.13.7, E.C.4.10.13
Joint Commission 2008 Standards: E.C.4.12.7, E.C. 4.18.1, E.C.4.18.2, E.C.4.18.3, E.C.4.18.4, E.C.4.18.6
NIMS Implementation Activity for Hospitals and Healthcare Systems: Element 12

Objective IV:
Assess the facility’s capability to track patients throughout the hospital, including the hospital-
based alternate care sites and to other patient care destinations, in accordance with applicable
law and regulations.
Joint Commission 2007 Standards: E.C.4.10.13, E.C.4.10.15, E.C.4.10.18
Joint Commission 2008 Standards: E.C.4.13.5, E.C.4.13.11, E.C.4.13.12, E.C.4.13.13, E.C.4.14.10, E.C.4.14.11,
E.C. 4.18

Objective V:
Exercise the ability to maintain reliable surveillance and communication capability to detect
outbreaks of infectious disease and to communicate response efforts to staff, patients, their
families and external agencies. Use appropriate forms and status reports.
Joint Commission 2007 Standards: E.C.4.10.7, E.C.4.10.8, E.C.4.10.10
Joint Commission 2008 Standards: E.C. 4.13.1, E.C.4.13.2, 4.13.3, E.C.4.13.4, 4.13.5, E.C.4.13.7
NIMS Implementation Activity for Hospitals and Healthcare Systems: Element 4

Objective VI:
Assess the ability to provide prophylaxis to hospital staff, physicians, volunteers, current
patients and others as appropriate, in consultation with local public health department.
Joint Commission 2007 Standards: E.C.4.10.7, E.C.4.10.8, E.C.4.10.10
Joint Commission 2008 Standards: E.C. 4.13.1, E.C.4.13.2, 4.13.3, E.C.4.13.4, 4.13.5, E.C.4.13.7
NIMS Implementation Activity for Hospitals and Healthcare Systems: Element 4

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Statewide Medical & Health Disaster Exercise
October 25, 2007

Objective VII:
Exercise the ability to expand and augment personnel resources during a prolonged surge
event, including the use of volunteers and community resources, for between 96 hours and
seven days.
Joint Commission 2007 Standards: E.C.4.10.10, E.C.4.10.15, E.C.4.10.20
Joint Commission 2008 Standards: E.C. 4.11, E.C.4.14.5, E.C.4.14.6, E.C.4.14.7, E.C.4.17.1, E.C.4.17.2,
E.C.4.17.3, E.C.4.17.4, E.C.4.17.5
NIMS Implementation Activity for Hospitals and Healthcare Systems: Element 8, 15 and 16

Objective VIII:
Assess the ability to prioritize, manage, and allocate resources, especially scarce resources
(e.g., ventilators, negative-pressure isolation capacity, personal protective equipment, critical
care beds, pharmaceuticals) during an infectious surge event.
Joint Commission 2007 Standards: E.C.4.10.10
Joint Commission 2008 Standards: E.C. 4.11.9, 4.11.10, E.C.4.14.
NIMS Implementation Activity for Hospitals and Healthcare Systems: Element 8, 15 and 16

Objective IX:
Demonstrate the ability to communicate facility needs to outside sources (e.g., vendors,
suppliers, EMS, city/OA stockpiles, corporate healthcare system) for essential supplies,
services, and equipment to ensure integrity of resource supply chain.
Joint Commission 2007 Standards: E.C. 4.10.8, 4.10.10, 4.10.18
Joint Commission 2008 Standards: E.C. 4.14.

Objective X:
Assess the ability to secure the hospital facility and grounds to protect staff, volunteers,
physicians, patients, visitors, and assets using internal and external resources.
Joint Commission 2007 Standards: E.C.4.10.10, E.C.4.10.21
Joint Commission 2008 Standards: E.C. 4.15.1, E.C.4.15.2, E.C.4.15.6, E.C.4.15.6, E.C.4.15.7, E.C.4.15.8
NIMS Implementation Activity for Hospitals and Healthcare Systems: Element 3 and 8

Objective XI:
Activate hospital laboratory policies and procedures to communicate to the local public health
laboratory and/or local Laboratory Response Network (LRN) to determine appropriate
specimen/sample preparation and shipment to the LRN laboratory.
Joint Commission 2007 Standards: E.C.4.10.8, E.C.4.10.10
Joint Commission 2008 Standards: E.C .4.11.4, E.C.4.13.3, E.C.4.13.4, E.C. 4.13.7, E.C.4.18.1
NIMS Implementation Activity for Hospitals and Healthcare Systems: Element 3 and 4

Objective XII:
Activate information management plans and develop public information messages consistent
with local authorities (OA Joint Information Center) and other healthcare providers in a rapid and
timely manner for internal (current patients, staff, volunteers, physicians, visitors) and external
(media, others) dissemination.
Joint Commission 2007 Standard: E.C.4.10.10
Joint Commission 2008 Standard: E.C. 4.13.6
NIMS Implementation Activity for Hospitals and Healthcare Systems: Element 3 and 4

Objective XIII:
Demonstrate the ability to activate established memorandums of understanding (MOU) between
the hospital and community partners, private entities, vendors and others as applicable.
Joint Commission 2007 Standards: 4.10.5, 4.10.6, 4.10.10, 4.10.15
Joint Commission 2008 Standard: E.C. 4.11.7, 4.11.8, 4.13.7, 4.14.1, 4.14.7, 4.14.8
NIMS Implementation Activity for Hospitals and Healthcare Systems: Element 8

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Statewide Medical & Health Disaster Exercise
October 25, 2007

Community Care Clinic/Medical Clinic Objectives

Objective I:
Activate the Emergency Operations Plan and the incident command system (e.g., the Hospital
Incident Command System [HICS]) to manage the biological surge event and large influx of
patients.

Objective II:
Exercise the ability to maintain reliable surveillance and communication capability to detect
outbreaks of infectious disease and to communicate response efforts to staff, patients, their
families and external agencies.

Objective III:
Assess the ability to provide prophylaxis to clinic staff, in coordination with local public health
department.

Objective IV:
Assess the ability to secure the clinic facility and grounds to protect staff, volunteers, physicians,
patients, visitors and assets, considering lockdown or closure of facility.

Objective V:
Assess the ability of clinic to expand patient capacity by utilizing non-traditional patient care
areas within the facility (e.g., office space, conference rooms) for the triage and treatment of
patients and/or acute care hospital transfers.

Objective VI:
Communicate approximate surge capacity and resource capabilities to the OA Medical/Health
point of contact (POC) utilizing appropriate communication systems.

Objective VII:
Assess capacity to assist other affected clinics in the OA with resources (e.g., staff, volunteers,
supplies, equipment, and mobile clinics).

Objective VIII:
Coordinate clinic response efforts with local hospitals, city public works, law enforcement, fire,
EMS, and volunteer emergency response teams as available (e.g., Medical Reserve Corps,
Community Emergency Response Teams).

Emergency Medical Services Providers/Ambulance Providers

Objective I:
Implement the provider’s emergency preparedness response plan using a recognized incident
command system (ICS).

Objective II:
Establish communications with the OA medical and health point of contact (POC) for guidance
and protocols on response activities.

Objective III:

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Statewide Medical & Health Disaster Exercise
October 25, 2007

Assess the ability to manage transportation of infectious patients, including infection control
measures.

Emergency Medical Services Providers/Ambulance Providers

Objective IV:
Exercise the triage, management, and coordination of a large number of patients during a surge
event, including protocols for determining primary and alternative patient transportation
destinations (e.g., community-based alternate care sites).

Objective V:
Assess the ability to sustain, maximize, and augment EMS staffing during a surge event.

Objective VI:
Assess the ability to provide prophylaxis to EMS staff, in coordination with the local public health
department.

Local Public Health Departments

Objective I:
Activate the incident command system (ICS) to manage the biological surge event and assist
healthcare providers with the management of the healthcare surge.

Objective II:
Exercise the ability of the Public Health Laboratory to respond to a biological surge event,
including specimen transport, agent identification, chain of custody procedures, and enhance
surge capacity through the Laboratory Response Network (LRN).

Objective III:
Exercise the decision-making processes required for the community and healthcare providers to
provide prophylaxis during the biological surge event.

Objective IV:
Assess the ability to provide prophylaxis for public health staff and essential personnel, as
appropriate.

Objective V:
Activate policies and procedures to communicate with hospital laboratories about proper
procedures for sample preparation and shipment to the Laboratory Response Network (LRN);
and, LRN notification of the State Laboratory.

Objective VI:
Assess the decision-making processes and procedures for establishing community-based
alternate care sites, including services and level of care to be provided. Identify the local
government entity responsible for site setup and operation of the community-based alternate
care sites. Activate the Standardized Emergency Management System to request resources.

Objective VII:
Assess the ability to coordinate and disseminate information in collaboration with the OA Joint
Information Center and local emergency managers, healthcare providers, and other officials.

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Statewide Medical & Health Disaster Exercise
October 25, 2007

Local Public Health Departments

Objective VIII:
Demonstrate the ability to access and transmit information to regional and state medical and
health authorities through CAHAN and to local healthcare providers through local
communication systems.

Operational Area Emergency Operations Center, Medical & Health Branch

Objective I:
Assess the OA Medical and Health Branch’s ability to collect timely, accurate, and appropriate
information from healthcare providers.

Objective II:
Implement Emergency Operations Center (EOC), Medical and Health Branch procedures and
mechanisms for managing a biological surge event, including the procurement, management,
and allocation of scarce resources within the OA.

Objective III:
Assess the ability to provide prophylaxis for EOC staff, in coordination with local public health
department.

Objective IV:
Demonstrate the ability to access, enter information into, and transmit Response Information
Management System (RIMS) data to regional and state medical and health authorities.

Objective V:
Assess the ability to activate and manage the Joint Information System to coordinate and
disseminate information in collaboration with local emergency managers, healthcare providers,
and other officials.

Objective VI:
Assess the ability of the OA to continue to provide essential services with in the county.

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Statewide Medical & Health Disaster Exercise
October 25, 2007

Exercise Scenario

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 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

BACKGROUND FOR THE SCENARIO

NOTE: The Statewide Medical and Health Disaster Exercise begins on October 25, 2007
at 5:00 am. This information is provided as scenario background to “set the stage” for
the events leading up to the day of the exercise.

October 2007

10-22-2007 Over the last week, the Department of Homeland Security (DHS) and the Federal
Bureau of Investigation (FBI) have been investigating credible intelligence
indicating international terrorist organizations are planning attacks against the
public health system in the State of California. Suspicious activity in or around
hospitals and medical clinics have been reported to DHS and FBI.

Reported incidents included a suspicious person asking questions about the

facility layout and the radiology department. On two separate occasions, a
person presented to hospitals claiming to be a surveyor for the Joint
Commission. In one California hospital, an astute staff member noticed a man
removing the evacuation maps, displaying floor plans, from the wall near
elevators. Hospitals conducted staff education, and heightened awareness and
security were initiated in the facility.

Local and Regional Terrorism Early Warning groups (TEWG) are on heightened
alert. The Department of Homeland Security raises the Homeland Security
Advisory System from “elevated” (Yellow) to “high” (Orange). The Governor’s
Office of Homeland Security notifies the California State Department of Public
Health (CDPH), Emergency Preparedness Office and the Emergency Medical
Services Authority (EMSA) about the threats.

There have also been isolated reports from the Transportation Security
Administration (TSA) employees about airport uniforms being stolen out of
lockers and from dry cleaners in the last two weeks. These incidents are under
investigation by the TSA. This information HAS NOT been shared with the public
or with the health care community.

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Statewide Medical & Health Disaster Exercise
October 25, 2007

10-23-07 Terrorist cells, located in multiple locations across California have been planning
Note: The an attack for over a year. The plan was to release a biological agent via aerosol
information in at airports throughout California. The plan was executed on 10-23-07 which was
this box (10-23) an exceptionally warm October day in airport waiting areas.
is for the use of
the Exercise The perpetrator(s) sprayed a cool mist on themselves and others in the terminal.
Planner/Control Since it was a hot day, the action went unnoticed by most and was even
ler only. Do not appreciated as a cooling measure by some. A couple of the waiting passengers
share this
were upset by the misting, and brought the behavior to the attention of the airline
information
with personnel at the gate. Airline personnel asked the perpetrator(s) to stop using
participants. their misting devices as it was irritating the passengers. The perpetrators moved
to another area within the terminal, remaining at the airport for several hours,
exposing not only boarding passengers but deplaneing passengers, airport
personnel and visitors as well. The perpetrator(s) discarded their canisters in the
trashcans and left the airport undetected.

A janitor emptying the trashcans found the canisters and, thinking them unusual,
reported the finding to his supervisor. The supervisor placed the canisters in a
bag and placed them on a shelf, but did not mention the unusual event to the
security department.

10-24-2007 Due to credible intelligence sources and “chatter” about a potential attack on the
2:00 pm public health system, the Department of Homeland Security (DHS) elevates the
Homeland Security Advisory System (HSAS) from “high” (Orange) to “severe”
(Red). The Governor’s Office of Homeland Security (OHS), in collaboration with
CDPH and EMSA, issues a public safety sensitive warning to California public
health departments, hospitals, and healthcare providers stating there is a
credible threat to the public health system. People in airports and other major US
cities are mentioned as possible venues for attack over the next several days.

The alert (see page 37) is communicated through communication channels to

hospitals and public health departments.

Pre-Event Discussion Points:

‰ How would your organization (hospital, clinic, EMS provider, or local public
health department) be notified of security alerts and/or credible threats to
healthcare infrastructure and whom would the information come from?
‰ What internal processes or procedures do you have to communicate
sensitive information on a “need to know” basis? To whom would the
information be communicated in your organization?
‰ When the Federal Homeland Security Threat Level is raised from Orange to
Red, are there any activities that would be activated, including increased
security measures? What internal and external notifications are activated?
‰ What other agencies or organizations would it be imperative to make contact
with and discuss protection of your critical infrastructure?
‰ What other opportunities, issues, and challenges do you identify given this
chain of events and in light of the elevation of the Homeland Security Threat
Level to Red?
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10-24-07 A 60-year old male, James, a smoker for many years, but non-smoking for
9:00 pm the last 10 years, with a history of coronary artery disease and emphysema,
presents at the hospital Emergency Department (ED) at 9:00 pm complaining of
a fever (103˚F), shortness of breath, and malaise. James reports a cough since
early this morning, and it is getting worse. He states he was feeling well
yesterday after he flew home on Tuesday morning (10-23-07). A chest x-ray
shows patchy bilateral infiltrates and consolidation. Hemoptysis develops. Lab
studies, including blood and sputum cultures, are obtained and antibiotics are
started. By midnight, James’ condition deteriorates and he is intubated and
placed on mechanical ventilation in the ICU.

10-25-07 Overnight, an unusual number of patients present to the hospital

Midnight to complaining of high fever, headache, muscle pains, chills, and malaise. The ED
4:00 am physicians and staff note the increased number of influenza-like-illnesses (ILI)
and hope it is not the start of a severe annual influenza season. The patients
with mild symptoms are discharged home with a diagnosis of influenza. They are
provided symptomatic care instructions to rest, increase their fluid intake, and
asked to follow up with their private physician in 48 hours if their condition has
not improved, or to return to the emergency department if symptoms worsen.
Several of these patients were visitors to the city and are staying at local hotels.
Eight patients with more severe symptoms are admitted to the hospital for care.
Two of the patients admitted with severe respiratory symptoms require
intubation.

10-25-07 Eight pediatric patients (all 10 years of age) are brought in by their parents with
5:00 am complaints of severe influenza symptoms of cough, high fever, headache, and
chills. Several of the parents accompanying the patients are also complaining of
similar symptoms. During the interview, the ED staff determine all eight pediatric
patients are part of a “pee wee” soccer team who attended a soccer camp last
weekend and took the same plane home on Tuesday, 10-23-07. The ill parents
accompanied the team to the camp and also flew home on Tuesday. The ED
staff are concerned about this outbreak of cases, and are worried about a cluster
of cases from the camp. Knowing there were also a high number of cases of ILI
during the night, the ED staff, preparing to go off shift at 7:00 am, write a report
for the oncoming shift reporting the cases to be communicated to the public
health department when it opens.

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 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

The Exercise Begins

October 25, 2007 at 0500
10-25-07 The patients admitted during the night are deteriorating and several more have
5:00 am been intubated and require mechanical ventilation. The hospital has no more
ventilators available in house (all are currently in patient use) and Central Supply
is contacting vendors to supply additional units as soon as possible. The
vendor(s) reports they cannot provide more than 1-2 additional ventilators
immediately due to increased demand overnight from other hospitals they
service. Several of these patients were visitors to the city and are staying at local
hotels

The ED is reporting a large ( ) number of patients (of all ages and health
condition) complaining of high fever and cough with foamy, bloody sputum, with
no history of previous illness. Due to the high number of admissions, additional
cases presenting to the ED, and lack of ventilator resources, the Nursing
Supervisor alerts the Administrator on Call. It is decided to activate the incident
command structure and the Hospital Command Center (HCC), formerly known
as the Hospital Emergency Operations Center, and begin staffing key positions
to address the surge of patients and the lack of critical resources.

Hospital key discussion points and actions;

‰ Who are the key people who can make the decision to activate the HCC?
‰ Once the decision is made to activate the HCC, what is the alert and
notification process and what personnel are notified?
‰ What key positions in the HCC incident management team structure should
be activated and why?
‰ What other agencies or organizations would you consider notifying of the
HCC activation? Who makes those notifications?

10-25-07 The hospitals within the community and OA are all reporting high census in
6:00 am the emergency departments and an increased number of inpatient admits with
severe influenza-like respiratory symptoms. EMS reports an increased volume of
911 calls and transports to the ED with the same symptoms. There is an
increase in ambulance diversion at the hospitals over the last 24 hours.

10-25-07 The night shift for the hospitals and EMS providers are preparing for shift change
7:00 am and giving report to the oncoming shift. The HCC and EMS shift supervisors are
requesting staff to remain on duty to assist with the increased census/call volume
and are actively calling in additional staff to meet the surge. The ED is holding
(insert number) patients waiting to be admitted.

The HCC is fully activated and personnel have arrived to staff key positions.

The hospital contacts the Local Public Health Department to report a large
number of influenza-like cases presenting to the hospitals.

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 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

7:00 am Hospital key discussion points and actions:

‰ Who determines activation of the high census plan or procedures to free up
or add patient beds to accommodate a large number of critical admissions?
‰ What strategies can be implemented to enhance emergency department
capacity?
‰ With the supply of ventilators severely limited, what strategies can be
implemented to procure additional ventilators?
‰ How will the assessment of priority for current and future use of ventilators be
managed in the hospital? Who will make the prioritization and use decisions?
‰ Will the hospital alter the process of regularly scheduled appointments or
non-emergency admissions at this time? How will information be
communicated to patients that may be affected by any changes?
‰ What epidemiology/infection control issues have been (or should have been)
identified and should be reported to the local public health department?
‰ What are the processes and mechanisms to notify the local public health
department of the outbreak?
‰ What potential challenges/issues may the hospital face in the next four hours
and what actions can be taken to mitigate or correct the issues?
‰ Within the hospital incident management team, are there medical or technical
specialists who could assist in decision-making?

EMS is receiving a high volume of 911 calls. The local Emergency Medical
Services Agency (LEMSA) has been notified of the increase in hospital
diversions and the increased volume of EMS calls.

EMS key discussion points and actions:

‰ What are the triggers/criteria/considerations for enhancing staffing to put
more ambulances in service to meet the 911 call volume demands?
‰ With an increased number of 911 patients with severe cough and ILI, what
increased personal protective/infection control measures should be
recommended to EMS crews?
‰ What potential challenges/issues may the EMS personnel face in the next
four hours and what actions can be taken to mitigate or correct the issues?
‰ Are there policies/procedures in place to relax transport guidelines and
response times? What triggers this policy?

10-25-07 The local public health department has been notified by hospitals in the area
8:00 am of the high numbers of cases with ILI including severe respiratory symptoms and
fever. The severity of the symptoms in the majority of the cases is particularly
concerning. Several of the patients have reported recent air travel. Public health
initiates surveillance and case investigation

The local public health department requests that hospitals report patient census
and bed counts by 9:00 am, using OA status report forms.

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 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

10-25-07
8:00 am Public health key discussion points and actions:
‰ What epidemiological information or testing is needed from healthcare
providers?
‰ How will the appropriate laboratory testing requirements be communicated to
the hospitals?
‰ How will the specimens be transported from the facilities to the public health
laboratory in accordance with applicable laws and regulations? How is chain
of custody maintained in a large scale event?
‰ How will public health staff be dispatched to hospitals to conduct
investigations? How many investigators are available for this and how long
will it take to dispatch them?
‰ How will information about the outbreak be disseminated to healthcare
providers, including non-hospital-based providers?
‰ What is the process for requesting hospitals to report bed counts and patient
census, and what forms or mechanism are used to report this information?

Upon interviewing several of the patients at the hospital, the public health
investigator determines all had been on an airplane on Tuesday, 10-23-07, or
had been in close contact with someone who had flown on that date. In addition,
the flights had originated from two particular airports.

Knowing of the security alert issued by DHS and OHS, the local public health
department notifies the CDPH, OA OES, and local law enforcement of the events
and the initial investigation results.

Healthcare providers are notified by the local public health department of the
outbreak and possible bioterrorism event. The local public health department
requests presenting-patients with symptoms be screened for recent air travel,
and all suspect cases to be reported immediately to the local public health
department. The public health department issues a public health alert
recommending respiratory etiquette/precautions.

The hospital has established facility perimeter security to control traffic because a
large number of people are arriving in vehicles. Parking lots are full and people
begin to park in places which obstruct the ED and hospital entrances.

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 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

8:00 am Hospital key discussion points and actions:

‰ What additional security measures can be implemented to enhance hospital
security?
‰ Should the hospital consider screening of all persons entering the hospital? If
initiated, how will this be communicated to EMS and ambulance providers?
‰ What PPE should be considered for security staff and staff assigned to
monitor entrances (e.g., lobby)? How do you ensure assigned staff have
appropriate PPE training?
‰ What is the procedure for reporting suspect cases to the local public health
department?
‰ How do you prioritize and triage patient care during a patient surge event,
and continue to maintain community care and regular appointments, while
accommodating the infectious patients?
‰ What is the appropriate process to ascertain current bed counts and patient
census to report to the local public health department? What are the
appropriate forms that should be used and how is the information
communicated?

10-25-07 Community clinics have opened and are quickly overwhelmed with the large
9:00 am number of patients presenting to the clinic with ILI, or calling for appointments to
be seen. Patients are reporting severe illness with high fever and cough. The
number of patients presenting with ILI and arriving without appointments are
overwhelming operations. Regular clinic patients with scheduled appointments
(e.g., diabetic care, hypertension follow up) are arriving at the clinic and are
angry because they cannot be seen.

Community clinic key discussion points and actions:

‰ How do you prioritize and triage patient care during a patient surge event,
maintaining community care and regular appointments, while accommodating
the infectious patients?
‰ What is the trigger to cancel or reschedule routine clinic appointments to
accommodate the surge of ILI patients?
‰ How will the rescheduling of routine appointments impact these patients and
their continuity of care?
‰ What infection control measures for staff and patients should be
implemented?
‰ Does your plan include isolating patients with ILI from the general clinic
population to decrease exposure?

10-25-07 Local media hear about the increased number of ill patients and the possibility of
9:30 am a bioterrorism event and quickly arrive at the hospitals, local public health
departments, and community clinics. They have been monitoring emergency
scanners and hear the number of EMS calls increasing. The media broadcasts
information, however limited and unconfirmed, about bioterrorism and expected
respiratory symptoms, and state the “only cure is for antibiotics to be taken as
soon as possible.” Public anxiety increases dramatically after hearing the
broadcasts and people begin presenting at hospitals, clinics, pharmacies, and
doctors offices demanding antibiotics.

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 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

Many healthcare providers are calling their employer to express anxiety about
coming to work and being exposed to the disease and subsequently exposing
their families.

Local law enforcement and FBI have been investigating a possible connection
between the victims and the airports. They have arrived at the airport and are
interviewing security staff. The airport security supervisor remembers the janitor
finding the canisters and supplies them to law enforcement. Airport security
tapes are reviewed which show the perpetrators “misting” the passengers in the
terminals. Samples from the canisters are sent to the State laboratory for
immediate testing and analysis.

Key discussion points and actions for all participants:

‰ How will you respond to the concerns and information needs of the on and
off-duty staff, patients, and visitors who are monitoring the news broadcasts?
‰ How will essential services be determined and provided in light or increased
patient numbers and decreased staffing?
‰ Has your Public Information Officer (PIO)/public affairs department been
activated?
‰ The PIO must prepare a press release in collaboration with the JIC, local
public health department, and local emergency management. What is your
facility policy for the release of information and media briefings?

Local, state, and federal law enforcement are arriving at the healthcare facilities
and local health department. They are requesting to immediately interview staff,
patients, and families and to take possession of any evidence, including medical
records.

Key discussion points and actions for all participants:

‰ What issues does law enforcement interviewing patients and staff pose to the
healthcare facility, staff, patients, local public health, and others?
‰ What policies and procedures are in place to guide and direct staff when
dealing with law enforcement requests?
‰ What facility policies guide evidence collection in a terrorism event and law
enforcement confiscation of patient belongings, valuables, and other items for
evidence?
‰ How will law enforcement personnel interviewing patients be oriented to and
provided with personal protective equipment? Are there additional
precautions that should be taken or required (e.g., limiting or denying contact
with infected patients)?
‰ Who will control and coordinate the release of information, access to the
patients, and release of medical records?

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 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

9:30 am Hospital/Clinic key discussion points and actions:

‰ How will the hospital/clinic deal with staff absenteeism issues? Are there
procedures or plans in place to address the issues?
‰ How will the hospital/clinic deal with staff that insist on leaving work to avoid
exposure?
‰ How does the hospital and/or clinic assess, triage, and determine the
allocation of scarce resources including acute care beds, ventilators, and
equipment? How are on-duty staff notified of these changes?
‰ Local law enforcement will be arriving to the facility to interview patients and
others. What patient information and medical records can be released to
FBI/law enforcement, in accordance with patient privacy and statutes?

10-25-07 All participants conduct a media briefing/press conference. Key

9:45 am discussion points and actions for all participants:

\
Key discussion points and actions for all participants:
‰ Who will be the spokesperson(s) for the hospital?
‰ How will pre-briefing planning be coordinated with health care and
emergency management partners?
‰ Where will the media briefing be conducted?
‰ Who will attend the media briefing in addition to the spokespersons?
‰ What information will be provided to the media?
‰ How will the agency conducting the media briefing ensure the information is
consistent with other response partners?

10-25-07 In the hospital, James, the 60 year old smoker, the index patient, who presented
10:00 am to the hospital on 10-24-07, arrests. Efforts to revive him are unsuccessful and
he is pronounced dead at 10:15 am. His family is distraught and talks to the
media immediately upon leaving the facility.

Hospitals and clinics are overwhelmed as the large numbers of patients who
continue to present for evaluation and care. Many of the patients presenting are
entire families, including children. Local public health departments are
overwhelmed with calls from the public reporting illness and demanding the
government protect them and give them antibiotics.

The decision is made within the hospital/clinic to designate an isolation “wing” or

area within the facility to cohort the possibly infectious patients.

Hospital key discussion points and actions:

† In consultation with the engineering department, infection control, and the
Incident Commander/Operations Section Chief and/or Director or VP of
Nursing, where should the designated isolation area be established?
o Patient care area
o Conversion of a non-acute patient care area
o Isolating patients in alternate care site outside of the hospital facility
† How can the Heating, Ventilation and Air Conditioning (HVAC) be controlled
in the designated area to ensure respiratory isolation?

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 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

10:00 am Hospital key discussion points and actions:

† What special considerations should be taken for the designated isolation
area?
o Security
o Staff assignment and protection
o Traffic flow and restriction of personnel, families and friends
o Morgue
o Supplies and equipment, including PPE
o Medical gases
o Nutritional Services
o Suctioning
o Air exchanges
o Biohazardous waste
† What additional resources or supplies (e.g., diapers, formula, cribs, and
pediatric-sized respiratory equipment) does the facility have to care for
children?
† How will you provide competent pediatric staff to care for the children
presenting and admitted to the facility?
† Does the facility have a plan to deal with children that are not sick or do not
need to be admitted, but arrive with a parent that does need to be admitted?

Across the OA, patients present with ILI. The hospitalized patients have
developed severe pneumonias, shortness of breath, hemoptysis, and many
require intubation. Hospitals are reporting high census and limited bed
availability, especially critical care beds. Large numbers of patients are requiring
intubation and mechanical ventilation with reports of multiple deaths due to
severe respiratory compromise, despite treatment. Respiratory therapy is
overwhelmed with requests for respiratory treatments for inpatients and
outpatients in the ED.

Clinics and physicians offices are referring acutely ill patients to the emergency
departments for evaluation and/or direct admissions. Large numbers of patients
are also being referred to x-ray and laboratory services.

Security at the hospitals, clinics, and public health departments has become a
critical issue. Large numbers of ill and asymptomatic people are presenting at
the facilities demanding care and antibiotics.

Hospital/Clinic key discussion points and actions:

‰ Security of the facility staff, current patients, and the facility is important.
What security measures should be taken to protect the assets? Limited
access? Lockdown?
‰ How will you orchestrate the security measures which will be implemented,
and what processes will you use?
‰ How will you communicate the security precautions and measures to the
arriving public?
‰ The public believes the hospital/clinic has medications to treat the disease.
How will you ensure the safety and security of the stockpiled equipment,
supplies, and pharmaceuticals?
‰ How will you coordinate with clinics and private physicians to control or
reduce transfers to your hospital?

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 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

10:00 am Hospital/Clinic key discussion points and actions:

‰ The hospital/clinic is receiving a large volume of calls for information and
services. Is your organization able to receive and process the calls?

Local public health key discussion points and actions:

‰ Until the infectious agent is positively identified, what actions, if any, can be
taken by local public health to allay public anxiety and demonstrate
government action?
‰ Given the possibility of a biological terrorism event, should the public health
department begin to make provision for the implementation of mass
prophylaxis?
‰ The public health department is receiving a large volume of calls for
information and services. Is your department(s) able to receive and process
the calls?
‰ The public knows the local health department has medications to treat the
disease. How will you ensure the safety and security of the stockpiled
equipment, supplies, and pharmaceuticals?
‰ What community mitigation measures might you consider prior to the
identification of the infectious agent?

EMS has been transporting potentially infectious patients to the hospitals from
homes and clinics across the community.

EMS key discussion points and actions:

‰ What procedures currently exist or must be implemented to decontaminate
the ambulances between transports?
† What measures have been taken to protect the staff during patient
assessment and transport?
† Are alternate care sites available for EMS/ambulances to transport non-acute
patients to instead of the acute care facility? How would you be notified that
alternate care sites have opened?
† What permissions or changes in protocols would be necessary for
ambulances to transport appropriate patients to alternate care sites or clinics
instead of the acute care hospital? Who would sanction alternate
destinations and provide guidelines to you (e.g., local EMS agency, local
health department/officer)?
† Has mass prophylaxis for the staff been arranged, and how is this information
provided to the staff?
† What measures have been taken to increase staffing and the numbers of
available ambulance units in service to accommodate the surge of patients?

10-25-07 The State CDPH laboratory notifies the local health officer and law enforcement
11:30 am regarding the agent found in the canisters sent for analysis was Yersinia pestis.
The local public health epidemiological investigation and contact tracing confirms
the patients identified were passengers on planes leaving from or arriving to the
airports, or were in close contact with a person who did travel by plane. A local
public health emergency is declared by the local health officer. Multiple counties
across the State of California are also reporting an outbreak of ILI with similar
histories. The local public health officer notifies the OA Executive Management
and OA OES of the outbreak and the intent to proclaim a Public Health

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 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

Emergency. Hospitals, clinics, EMS providers, other healthcare agencies and

community partners are notified by local public health or designated agency.

The local health officer proclaims a Public Health Emergency for the Operational
Area and notifies State OES, CDPH, and public health officers of adjacent
jurisdictions. CDPH notifies the sentinel providers (see glossary for definition) of
the outbreak and recommends heightened surveillance. State OES Warning
Center activates the alert system, notifying key state and local government
agencies.

Local public health and CDPH publicly announces the case definition for Yersinia
pestis presenting as pneumonic plague. The case definition and treatment
recommendations are:

History
• People who have recently been in or traveled through [name of local or
nearby] airport on 10-23-07
• Employees of [name of local or nearby] airport on duty on 10-22 through
10-24-07

Symptoms
• Fever (>101.5F) and chills
• Headache
• Rapid, difficult breathing and cough
• Rapidly progressing pneumonia
• Hemoptysis (bright red or foamy red)
• Rapid shock
• Sudden death
• Chest x-ray findings consistent with pneumonia (bilateral lobar infiltrates)

Diagnostic Testing
• Blood cultures for plague bacteria
• Microscopic examination of lymph gland, blood, and/or sputum (using
Gram and other special stains)
• Fluorescent Antibody or ELISA antigen testing of sputum specimens
• Serological confirmation of Yersinia pestis

Treatment for active cases

• Antibiotic treatment should begin as soon as possible after laboratory
specimens are obtained
• Streptomycin is the antibiotic of choice
• Gentamycin is used when streptomycin is not available
• Tetracyclines and chloramphenicol are also effective

Isolation Precautions
• Patients should be isolated for droplet precautions. Airborne isolation
precautions are not necessary
• Reinforce respiratory hygiene/cough etiquette, based on CDC guidelines

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 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

Prophylaxis treatment
• Seven day course of doxcycline, Cipro or trimethoprim-sulfaethoxazole,
chloramphenicol (supported by several references but all may not be FDA
approved)
• A vaccine for plague is no longer available in the United States

The local public health departments and the Medical and Health Operational
Area Coordinator (MHOAC) are receiving requests for medication from hospitals
and clinics whose supplies are limited and are currently being used to treat
inpatients with symptoms. Local Hospital Preparedness Program medication
caches for hospital and first responder staff have been distributed. Those
counties with local public health medication stockpiles for mass prophylaxis are
anticipating that the medications will be exhausted by the 27th of October 2007 at
12 noon. The local EOC, OA emergency management, and local senior officials
are requesting antibiotics through the local public health department.

Local public health medication stockpiles for mass prophylaxis are anticipated to
be exhausted by October 27, 2007at 12 noon.

Community and hospital-based alternate care sites must be established to

provide additional medical care access to the public. Local public health is
currently considering recommendations for non-medical containment measures
(e.g., school dismissals, canceling social events) and social distancing.

Weather conditions across the State per the National Weather Service and local
meteorologists: “Unseasonably warm weather, highs expected in the mid 90’s,
partially cloudy with light winds through October 28, 2007. Lows at night will be
65 with light winds.”

Hospital key discussion points and actions:

‰ What are your facility’s current inventory/stockpile of medications to treat the
primary and secondary infections?
‰ What is the current stockpile/availability of medications in liquid form or in
pediatric dosages to administer to pediatric patients?
‰ Yersinia pestis has been confirmed as the infectious agent. What appropriate
isolation precautions should be implemented?
‰ How will you prioritize and allocate the use of the medications?
o For current patients (symptomatic)?
o For exposed but asymptomatic staff?
o As prophylaxis for staff at high risk for exposure (e.g., caring for
infected patients, ED staff)?
o For staff members families?
o External community responders (e.g., law enforcement, EMS, Fire)

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 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

10-25-07
11:30 am Hospital key discussion points and actions:
‰ Does you hospital emergency operations plan address the implementation of
altered standards of care during a surge event?
o How and by whom will the decision be made to implement altered
standards of care?
o What criteria would be utilized for altering standards of care?
o How will you triage and prioritize the use of existing ventilators?
o How will implementation of altered standards of care be tracked and
evaluated?
‰ You must now establish hospital-based alternate care sites/alternate patient
care locations to accommodate the surge of patients.
o What logistical and staffing issues does this present to the facility?
o How will patients be triaged and moved to the alternate care site?
o Weather conditions must be taken into account in the establishment of
alternate care sites. How will this impact the plans?
o What is your procedure for notifying local CDPH Licensing and
Certification offices about the plans to establish alternate care sites?
o Are there other waivers that might be needed and requested from
CDPH Licensing and Certification? (e.g., waiver of nurse/staffing
ratios)
‰ What additional space and resources can be procured from outside of your
facility to provide patient care and accommodate the surge? Are there any
memorandums of understanding (MOUs) that could be activated?
‰ What are the procedures to communicate resource needs when you facility
has or will soon exhaust current supplies?
‰ How will you track patients throughout the hospital, including the hospital-
based alternate care sites and to other patient care destinations, in
accordance with applicable law and regulations?
‰ What communication and status reports are you maintaining with vendors of
equipment, supplies, and outside services (e.g., linen, food)?
‰ Would the hospital consider providing prophylaxis to vendors and suppliers to
ensure business continuity?
‰ What communication and status reports are you providing to the OA medical
and health point of contact?
‰ How will the following local public health decisions and actions impact
healthcare provider staffing and what mitigation efforts can be undertaken?
o School dismissals, in conjunction with the local Department of
Education?
o Social distancing, including cancellation of public events and public
gathering sites?
o Closure of child and adult day care centers?
‰ What is your system for tracking potential employee exposures?
‰ The hospital may be contacted by local law enforcement for names of
patients presenting with symptoms or history of exposure. What is the
hospital policy and procedure(s) on releasing patient information to law
enforcement?

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 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

10-25-07
11:30 am Clinic key discussion points and actions:
‰ Your clinic’s current in-house supply of treatment/prophylaxis medications is
severely limited, if available at all. How will you provide prophylaxis to staff?
‰ Patients seen in the clinics are given prescriptions for the medications to treat
minor symptoms or as prophylaxis for exposures. The patients are returning
to the clinics very angry because local pharmacies have run out of the
medications and they cannot fill their prescriptions. What strategies will
address these issues?
‰ Yersinia pestis has been confirmed as the infectious agent. What appropriate
isolation precautions should be implemented?
‰ What additional space and resources can be procured from outside of your
facility to provide patient care and accommodate the surge? Are there any
MOUs that could be activated to assist?
‰ What communication and status reports are you maintaining with vendors of
equipment, supplies and outside services (e.g., linen)?
‰ Would the clinic consider providing prophylaxis to vendors and suppliers to
ensure business continuity?
‰ What communication and status reports are you providing to OA medical and
health point of contact?
‰ What is your system for tracking potential employee exposures?

Local public health key discussion points and actions:

‰ With the confirmation of Yersinia pestis, mass prophylaxis should be
considered.
o What are the decision making processes for activating mass
prophylaxis plans and establishing Points of Dispensing (POD) in the
community/county?
o What staffing and logistical concerns does the activation of PODs
present to the local or State health departments?
o Weather conditions must be taken into account in the establishment of
alternate care sites and/or PODS. How will this impact the plans?
‰ What is the process for requesting treatment/prophylaxis medications and
critical patient care supplies and equipment from regional, state, and/or
Federal resources?
‰ What are the triggers to activate standing orders and protocols, if they exist,
for the implementation of mass prophylaxis? If they do not exist, what are the
decision-making processes to implement mass prophylaxis?
‰ What recommendations will be provide to healthcare providers about the
prioritization and allocation of prophylaxis medications?
o For current patients (symptomatic)?
o For exposed but asymptomatic staff?
o As prophylaxis for staff at high risk for exposure (e.g., caring for
infected patients, ED staff)?
o For staff members families?
o External community responders (e.g., law enforcement, EMS, Fire)
‰ How will the information about PODs be communicated to healthcare
providers for patient referral and to the public?
‰ Once a local public health emergency is declared by the health officer, how is
this information disseminated to healthcare providers, government agencies,
surrounding OAs, the Region, the State, and the public?

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 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

10-25-07
11:30 am Local public health key discussion points and actions:
‰ What is your system for tracking potential employee exposures?
‰ What Risk Communications messages do you have already prepared?

10-25-07 The Governor of the State of California declares a State of Emergency.

12:00 pm The local public health department issues a public health alert, and advisories
recommending the following groups of people present to the mass prophylaxis
clinics:
• Those who flew on a plane on October 22 or 23, 2007 from [name of local
or nearby] airport and do not have any fever, cough or illness. Public
members are asked to bring documentation of the flight to the mass
prophylaxis clinic, if available.
• People who have recently been in or traveled through [name of local or
nearby] airport on 10-23-07
• Employees of [name of local or nearby] airport on duty on 10-22 through
10-24-07

Local public health is also urging other persons without symptoms or suspected
contact to remain at home and seek medical care only if they develop symptoms
such as high fever, cough, or bloody sputum.

Hospitals are reporting high census and lack of resources, including personnel,
beds, medications, and durable medical equipment. Ventilators have reached a
critical level and assistance is needed immediately in order to save lives.
Requests for resources have been submitted to the local public health
department, the MHOAC, and to the OA EOC.

All departments in the hospital have been impacted by the high census, lack of
resources, and the outbreak of an infectious disease.
• Many of the hospital staff continue to call in sick for their shifts,
complicating the personnel staffing situation.
• The hospital laboratory staff are asking what to do with the overwhelming
number of sputum and blood specimens they are receiving for
processing. The lab manager reports this situation is critical and it must
be addressed immediately.
• High census plans are activated in the hospitals and all appropriate
patients who can be discharged or transferred to alternate care facilities
are being processed.
• Negative pressure isolation rooms’ capacities are inadequate to meet the
patient load.
• Droplet precautions are instituted in the facility.
• There have been 25 deaths in the hospital reported as of this time. The
coroner has been notified, but is unable to respond for several hours, if
not days.

28
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

10-25-07
12:00 pm Hospital key discussion points and actions:
‰ What can be done to immediately address the concerns of staff?
‰ How can personnel be augmented?
‰ How will personal protective equipment be allocated among staff, physicians,
and volunteers?
‰ What other resources are available to your hospital lab to assist with
specimen processing?
‰ How will you expand isolation capacity within the facility to accommodate the
large numbers of infected or potentially infected patients?
‰ Your morgue capacity is limited, and there have been 25 deaths. What
provisions for storage, security, and evidence preservation of the bodies must
be implemented?
‰ What type of mask is required for staff caring for infectious patients? Is the
N-95 Respirator required or can the staff be protected with standard masks?
Who could provide this information to you in your community or from within
hospital resources?
‰ What provisions do you have for “just in time” fit testing and training for
personal protective equipment (PPE)?
‰ Has a triage area and processes been established to immediately identify
and isolate patients presenting with suspicious symptoms from the general
population?
‰ Has triage, support, and education been established for
asymptomatic/unexposed persons presenting to the ED, clinics, medical
offices and calling 911?

Clinics are overwhelmed with the surge of patients and have severely limited or
lack equipment and supplies. Staff and physicians are exhausted from the
patient volumes and level of anxiety/anger of the public presenting to the clinics.
One patient has died in the clinic, and the coroner states they will not be able to
respond for days. The deceased patient’s family is very upset and wants to stay
with their loved one until the body is removed by the coroner.

Clinic key discussion points and actions:

‰ What actions should be considered by the clinic in light of the overwhelming
patient volumes, patient needs, lack of resources, and exhausted staff?
‰ What are your options and processes to acquire additional equipment,
supplies, and pharmaceuticals?
‰ How will you respond to the concerns and information needs of the staff,
patients, and visitors who are monitoring the news broadcasts? What
messages should be developed to address their needs?
‰ How can you augment personnel and staffing of the clinic?
‰ How will you manage the deceased? Storage, security, and evidence
preservation?

29
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

10-25-07
12:00 pm Local public health key discussion points and actions:
‰ Additional community-based alternate care sites are needed to meet the
community surge of patients and decompress the load on the acute care
facilities in order to maintain critical resources for the acutely ill. Should
community alternate care sites be established to meet the surge?
o Who makes the decision to open community-based alternate care
sites and what other internal or externals agencies should be involved
in the decision?
o What staffing and logistical challenges does the opening of alternate
care sites present to the local public health department?
o How will you communicate the decision to open or not open
community-based alternate care site(s)?
o If the alternate care sites are opened, what local government entity
can provide large quantities of supplies and equipment?
o If supplies, equipment, and staffing resources are not available locally,
how will you obtain these resources from other entities? Who is
responsible for contacting other agencies to obtain the resources?
o What community resources are available to support operation of the
alternate care site(s)?
‰ What other resources are available to your Laboratory Response Network
(LRN) and your public health lab to assist with specimen processing and
reporting?
‰ How is information shared and coordinated within the OA, region and state
entities?
‰ How will the local public health department manage the
asymptomatic/unexposed or “worried well”?

EMS providers continue to report a high volume of 911 calls and are unable to
meet the demand of calls with available staff and vehicles. The majority of calls
continue to be complaints of respiratory distress and influenza-like symptoms.

EMS key discussion points and actions:

‰ What infection control precautions have been taken for EMS/ambulance
personnel?
‰ Who has the authority to establish altered triage and dispatch priorities to
ensure ambulances are dispatched appropriately?
‰ What other EMS/ambulance resources (e.g., additional rigs and staff) are
available to you?
‰ What is the decision-making process to convert an ALS staffed rig into a BLS
staffed rig in order to increase the number of ambulances available?
‰ What medications and supplies are severely limited? What is the process of
re-supplying critical equipment and supplies if hospitals and vendors cannot
provide resources through normal supply chains?
‰ What are the decision-making processes to determine altered standards of
care for EMS patients?

30
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

10-25-07 Media from across the state and nation are reporting the biological terrorism
12:30 pm event. There are reports from neighboring county health departments of similar
cases being reported in their emergency departments and clinics, and strict
isolation of the patients is being instituted. National news services and media are
now arriving at hospitals, clinics, local health departments, and governmental
agencies demanding information.

With the media reports, a large number of convergent volunteers present at

hospitals and clinics wanting to help.

Law enforcement continues to investigate and interview patients, families and

staff.

Businesses across the local area report high absenteeism because people are ill,
are caring for ill family members or are afraid to leave their homes. Community
alerts are being broadcast on radio and television to provide accurate information
to the public.

10-25-07 The OA is reporting the following statistics:

12:30 pm (Note: Please customize the OA statistics to simulate mass casualty event and
capacity overload. Hospitals may also simulate the statistics to meet individual
needs for exercise play.)

Statistics for the OA:

Number of patients admitted with possible pneumonic plague:

Number of patients treated and triaged to home with symptomatic care, including
mild symptoms, the asymptomatic/unexposed (e.g., worried well) and pre-
symptomatic patients:

Number of patients waiting to be seen:

Estimated number of persons requiring mass prophylaxis:

Number of deceased:

The hospital and clinic emergency plan is activated and the HCC/Clinic EOC
open. The OA EOC has been activated and the medical and health branch,
including the MHOAC continues to call for status reports, bed availability and
critical issues.

Healthcare resources within the community and operational area have been
severely taxed and hospitals and clinics are at maximum capacity. Physicians in
the emergency department, clinics, and medical offices, as well as EMS
providers, are requesting information and treatment recommendations for the
presenting symptoms of the patients that continue to flow into the system.
Information and recommendations being requested include:
• An updated case definition, if different from earlier definition
• Recommended isolation for patients presenting with suspected or
probable symptoms
31
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

• Personal protective precautions for healthcare staff and first responders,

and how to protect staff with limited resources
• Updated recommended treatment plan
• Locations and scope of PODs and appropriate referral of patients seen by
clinics, hospitals, and EMS providers
• Location and scope of community alternate care sites, if established, and
appropriate triage and referral of patients presenting to clinics, hospitals,
and EMS providers

10-25-07
12:30 pm Local health department key discussion points and actions:
‰ How will you develop risk communication messages to address the
information and recommendation needs of healthcare providers?
‰ How rapidly (and realistically) can these messages be developed, approved,
and disseminated?
‰ How will you collaborate with the Joint Information Center to ensure
consistent messages?
‰ How will you disseminate the risk communication message and
recommendations?
o To healthcare providers?
ƒ Hospitals
ƒ Clinics
ƒ EMS
ƒ MD offices
ƒ Long term care facilities
ƒ Others
o To the public?
o To the media?
o To government officials and other responders?

Hospital, EMS, and Clinic Key discussion points and actions:

† How do you identify patients seen in previous days before the biological
agent was identified?
† How do you identify, monitor, and provide follow up to exposed staff?
† Who within your community/OA can provide your organization with the
information and recommendations requested above?
† Does your facility/service have a plan and procedures to manage and utilize
convergent volunteers who present to assist?

10-25-07 Healthcare Provider Status Update

1:30 pm
The critical care unit(s) in the hospital are at capacity and there are no additional
Intensive Care Unit (ICU) beds. The emergency department (ED) is holding
number (insert appropriate number of ED patients to increase
strain on resources) of patients awaiting inpatient beds, including ICU, telemetry,
medical surgical, and negative pressure isolation rooms.

The influx of patients presenting to the ED continues in a steady stream,

overwhelming resources, including staff (all levels of healthcare providers). There
is a lack of ED space, patient care equipment (gurneys, oximeters, ventilators,

32
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

oxygen sources), supplies (medications, patient care supplies), and personal

protective equipment (N-95 respirators).

EMS is reporting an increased volume of 911 calls with the chief complaint of
shortness of breath, cough, and fever requiring transportation to the hospital.
The hospitals have been on and off diversion status; however, now all hospitals
are reporting “closed status”, therefore all hospitals are required to be open to
ambulance traffic. With the volume of 911 calls requiring ambulance transport
and high ED and inpatient censuses, EMS providers are greatly delayed in
delivering the patient and transferring the care of the patient to the hospital staff
upon arrival, resulting in decreased availability of EMS responders for new 911
calls.

Clinics are reporting large numbers of patients presenting with complaints of

respiratory symptoms and do not have the resources to triage the patients.
Patients with severe symptoms must be held in the clinic for long periods of time
due to high patient census in the EDs and lack of EMS transporters.

Local public health has declared a public health emergency and is activating
mass prophylaxis/POD plans and will establish mass prophylaxis clinics to treat
the public. Estimated time for opening the PODs is 7:00 pm tonight. Local public
health releases or alerts to the media will be made available in order to inform
and educate the public about the disease symptoms, prevention, when to seek
medical care, and the availability and location of mass prophylaxis clinics.

10-25-07 All hospitals, clinics, EMS providers, and local public health departments begin
1:30 pm planning for a shift change at 3:00 pm. The upcoming operational period will be
from 3:30 pm until 11:00 pm. Incident Action Planning meetings are scheduled
for 2:00 pm.

Key discussion points and actions for all participants:

‰ What is the current situation status of the facility/service?
‰ What are the critical issues and resources?
‰ What are the operational objectives for the operational period of 3:30 pm until
11:00 pm?
‰ What staffing is needed?
‰ How are limited resources being allocated and prioritized? Who makes these
decisions and how are they conveyed to the staff and community?
‰ How will the facility be staffed?
‰ How will the HCC/EOC/Department Operations Center be staffed? Can any
positions be demobilized?
‰ What community “volunteer” resources can be utilized by your facility to
assist with the surge of patients which are expected to continue for an
extended period of time?
‰ How will you address the behavioral health/psychosocial needs of the staff,
volunteers, physicians, patients, and their families?
‰ How will your facility or service ensure business continuity, maintenance of
those essential or critical services, and continue to provide community care
services?
‰ How will your facility deal with the substantial increase in sanitation needs,
demand for food/drink, and patient holding areas due to the patient surge?

33
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

Each facility and service develops a written Incident Action Plan (IAP) for the
next operational period and disseminates it within the facility/service, to the
MHOAC, and to the local public health department.

Key discussion points and actions for all participants:

‰ What other organizations or responders could/should also receive the IAP to
facilitate communication and response among partners?
‰ How will you communicate the IAP to the appropriate agencies?
‰ From which agencies would it be helpful to receive their IAPs?

10-25-07 ALL EXERCISE PARTICIPANTS EXECUTE A TRANSFER OF

3:00 pm COMMAND/SHIFT CHANGE
‰ Conduct an incident briefing and report of current situation status
‰ Announce a formal transfer of command
‰ Report the IAP for the next operational period. (The IAP forms under ICS
and HICS include forms 201, 202, 203, 204 and 261)
‰ Replace off going personnel with oncoming personnel (or simulate a
change of positions in the command centers)

10-25-07
4:00 pm Local public health has established mass prophylaxis clinics in the following
locations:

1. 2.

3. 4.

5. 6.

Public health alerts are broadcasted on all media, including television, radio, and
neighborhood meetings to inform the public and decrease anxiety. The local and
national media are “camped out” at hospitals and the health department waiting
for updates and becoming restless. The media has obtained information that the
Centers for Disease Control and Prevention (CDC) are en-route and they
broadcast that the incident is bioterrorism.

A press conference is scheduled for 4:30 p.m. with the public health officer,
appropriate hospital and clinic representatives, and local government officials.

34
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

10-25-07
4:00 pm Key discussion points and actions for all participants:
‰ What community or governmental agencies should participate in the press
conferences (e.g., public health department, healthcare facility officials, local
government, and physicians)?
‰ Who is the most appropriate person(s) to represent the healthcare facility at
the press conference(s) and who makes this decision?
‰ How often should the press conferences be scheduled?
‰ Where should the press conferences be convened within the community?
‰ Who is the lead agency for the press conferences?
‰ What steps have been taken to ensure a consistent message among the
healthcare community and all levels of government agencies/officials? Who
makes the final decision about information to be conveyed when there is
conflict among the responding agencies?

10-25-07 The hospitals, clinics, and EMS providers are experiencing a shortage of
4:30 pm equipment, supplies, and facilities to care for patients. The shortages will be
critical within 12 hours, including the following essential items:
• N-95 Masks and other respiratory protective equipment
• Ventilators
• Oxygen tents to accommodate pediatric patients
• Antibiotics
• Isolation facilities
• Morgue facilities
• Beds, gurneys, cots
• Healthcare providers and staff support personnel
• Pediatric equipment (e.g., masks, ET tubes, oxygen tents)

Hospitals, clinics, EMS, and the local public health department construct
contingency plans to address the upcoming critical shortages. Vendors are
contacted to provide the additional supplies and equipment, but the vendors state
they will not deliver to the facility due to possible exposure of the delivery
personnel.

Many patient deaths have been reported at the hospitals and the hospital morgue
resources have exceeded capacity. The deaths are considered medical
examiner’s (coroner’s) cases and potential evidence in a biological terrorism
incident.

Key discussion points and actions for all participants:

‰ Activate current processes and procedures to procure essential resources
needed currently and for the next 24 hours.
‰ If no processes or procedures exist, what possible actions and plans can be
taken to procure the resources?
‰ Can vendors be protected from exposure or provided prophylaxis to ensure
delivery of needed resources?

35
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

10-25-07
4:30 pm Key discussion points and actions for all participants:
‰ What resources and mechanisms are available to procure the needed
supplies and equipment and who or what agency is contacted to provide
those resources?
o Intra-hospital resources
o Inter-hospital resources
o Community resources, including city and county
o County resources, including the MHOAC in the EOC
o Others
‰ What are the proper channels of communication and who or what agency is
contacted to obtain those resources?
‰ What non-medical resources may be needed in the event (e.g., security, law
enforcement, sanitation, water, transportation)?
‰ How will you maintain evidence/chain of custody for the dead bodies resulting
from the bioterrorism/mass casualty event?

10-25-07 All facilities, agencies, and providers report status to the OA. The OA and EOC
4:45 pm compile the reports, enter information into RIMS and place mission requests as
appropriate. The Regional Emergency Operations Center (REOC) begins to
receive reports from the OA and relays the information and resource requests to
the Joint Emergency Operations Center (JEOC) and the State Operations
Center.

10-25-07 THE EXERCISE ENDS

5:00 pm All participants conduct an exercise debriefing with HCC and departmental
staff immediately upon termination of the exercise.

Post exercise activities may include:

‰ Formal debriefing and incident review session with key personnel and the
Emergency Preparedness Committee.
‰ Development of an After-Action Report (AAR).
‰ Development of a Corrective Action Plan (CAP), including timelines and
deadlines for improvements.
‰ Dissemination of the AAR and CAP to key internal and external stakeholders.
‰ Planning for the next exercise.

36
Intelligence Messages
For Exercise Use only

37
 CA Statewide Medical & Health
Disaster Exercise
PUBLIC SAFETY SENSITIVE / NOT FOR PUBLIC
DISSEMINATION
THIS IS AN EXERCISE
22 October 2007, 1600 Hrs. (Page 1 of 2)
THREAT LEVEL CHANGED FROM YELLOW TO ORANGE
This intelligence bulletin provides law enforcement and other public safety officials with
situational awareness concerning international and domestic terrorist groups and tactics.

Handling Notice: Recipients are reminded that intelligence bulletins contain sensitive terrorism
and counterterrorism information meant for use primarily within the law enforcement and
homeland security communities. Such bulletins shall not be released in either written or oral
form to the media, the general public, or other personnel who do not have a valid need-to-know
without prior approval from an authorized Intelligence Community official.

Key Findings
The Intelligence Community is currently investigating credible intelligence indicating that
international terrorist organizations are planning attacks against critical infrastructure targets
within California, and specifically the medical and public health system in the State of California.

International terrorist organizations—especially the Universal Adversary (UA)—remain the

primary threat. Threats issued by UA and its affiliates, and attacks around the world indicate
international terrorists regard the medical sector facilities as high-priority targets, causing
medical facilities to be potentially at risk.

Suspicious activities in and around medical and public health facilities (specifically hospitals and
medical clinics) have been reported regularly to local and federal law enforcement. While the
majority of such incidents have posed no immediate threat, they may represent or resemble
terrorist preoperational (dry run) activities.

Continuing UA Interest in Targeting Critical Infrastructure

A series of statements from UA and its affiliates have encouraged targeting critical
infrastructure, including the public health and medical sector.

38
CA Statewide Medical & Health
Disaster Exercise
PUBLIC SAFETY SENSITIVE // NOT FOR PUBLIC DISSEMINATION
THIS IS AN EXERCISE
 CA Statewide Medical & Health
Disaster Exercise
PUBLIC SAFETY SENSITIVE / NOT FOR PUBLIC
DISSEMINATION
THIS IS AN EXERCISE
22 October 2007, 1600 Hrs. (Page 2 of 2)
UA views critical infrastructure targets such as hospitals and medical clinics as attractive and
viable targets because of the vulnerability and ease of access to medical facilities. An attack
would have significant iconic, economic and psychological impact.

• In previous statements posted on UA websites, a spokesman urged UA members to attack

medical personnel and hospitals in countries around the world on the grounds that the United
States is poisoning UA culture and aiding the enemies of UA.

• The UA-affiliated Global UA Media Front (exercise only) published an electronic handbook that
encourages economic attacks and urges the targeting of public health infrastructure—to include
facilities, individuals associated with hospitals, clinics and other healthcare facilities and related
infrastructure.

Possible Pre-operational Activity in the Homeland

Suspicious activities at US healthcare facilities—to include incidents of possible surveillance—
are reported regularly to local law enforcement and the FBI. While the majority of these
incidents are resolved through investigation, some have raised concern within the intelligence
and law enforcement communities of possible links to terrorist preoperational planning. As a
result the Intelligence Community is raising Homeland Security Advisory System from Yellow to
Orange for the Public Health Sector.

Orange indicates a high threat of terrorist attacks.

This assessment is Public Safety Sensitive. Distribution is authorized to public officials, public safety and public health and
healthcare personnel, including incident command personnel. Distribution or further dissemination beyond those agencies
is not authorized.

39
CA Statewide Medical & Health
Disaster Exercise
PUBLIC SAFETY SENSITIVE // NOT FOR PUBLIC DISSEMINATION
THIS IS AN EXERCISE
 CA Statewide Medical & Health
Disaster Exercise
PUBLIC SAFETY SENSITIVE / NOT FOR PUBLIC
DISSEMINATION
THIS IS AN EXERCISE
24 October 2006, 1700 Hrs. (Page 1 of 2)
THREAT LEVEL CHANGE FROM ORANGE TO RED
This intelligence bulletin provides law enforcement and other public safety officials with situational and
tactical awareness concerning international and domestic terrorist groups and tactics.

Handling Notice: Recipients are reminded that intelligence bulletins contain sensitive terrorism and
counterterrorism information meant for use primarily within the law enforcement and homeland security
communities. Such bulletins shall not be released in either written or oral form to the media, the general
public, or other personnel who do not have a valid need-to-know without prior approval from an
authorized Intelligence Community official.

Key Findings:
Intelligence sources and assessment indicate the significant potential for attack in the US or against US
interests abroad and within the Continental United States. California critical infrastructure targets and
other major US cities are specifically mentioned as possible venues for attack during the next several
days. Multiple suspected terrorist operatives have been arrested in California in what appears to be their
final attack planning phase. It is clear that a major multi-faceted, coordinated terrorist attack is probable.
It is not clear is how many other operatives and terrorist cells are involved.

On 22 October 2007, the Homeland Security Advisory System (HSAS) level was increased from
Elevated (Yellow) to High (Orange). The threat level was elevated due to the US Intelligence
Community's assessment of intelligence reports indicating anti-US terror group’s intentions of a possible
attack. The Department of Homeland Security Secretary, advised key Operational Area officials,
including state and local government, law enforcement, public health and other executives of the
heightened level of threat. The Secretary specifically stated that the threat indicators are “perhaps
greater now than at any point” since 11 September 2001, and that US Intelligence agencies have
“received a substantial increase in the volume of threat-related intelligence reports.”

Current intelligence reveals Universal Adversary’s (UA) continued interest in the use of aircraft as a
weapon in suicide attacks. Additionally, there have been repeated unsubstantiated reports regarding the
threat of the use of biological weapons in a “massive” attack against the US, resulting in significant
casualties, far exceeding the attack on 11 September 2001. Potential attacks may include a variety of
terrorist tactics, techniques and procedures, including suicide operations, Vehicle Borne Improvised
Explosive Devices, small assault teams, unconventional weapons, maritime and infrastructure attacks.
Soft targets continue to be a subject of concern; these targets include hospitals, and medical clinics.

Public safety personnel should be aware that UA previous tactics include large vehicle borne explosives,
surface-to-air missile attacks, as well as the use of various vehicles (trucks, boats, and planes) in suicide
operations. Documents and videotapes recovered overseas indicate UA and aligned groups are also
40
CA Statewide Medical & Health
Disaster Exercise
PUBLIC SAFETY SENSITIVE // NOT FOR PUBLIC DISSEMINATION
THIS IS AN EXERCISE
 CA Statewide Medical & Health
Disaster Exercise
PUBLIC SAFETY SENSITIVE / NOT FOR PUBLIC
DISSEMINATION
THIS IS AN EXERCISE
24 October 2006, 1700 Hrs. (Page 2 of 2)
interested in armed assaults and possibly even sniper attacks. UA’s interest and capability for executing
chemical, biological or radiological attacks remains a concern.

Transportation and aviation sectors are considered at risk, and the threat from suicide bombers persists.
As previously assessed, the global terrorist threat is expected to mature and evolve over the long term.
UA, in its many variations and through its affiliates, continues to manifest a viable threat against US and
Western interests worldwide and can be expected to attempt to conduct operations within the US and
European nations when they have the capability and when it meets their objectives. It is likely that UA
and affiliated entities will seek to conduct operations wherever possible to demonstrate their operational
and philosophical relevance.

The Intelligence Community considers this a high risk time period. It is our assessment that the
greatest period of risk is from now through 26 October 2007, although the threat period is short,
significant awareness must be maintained for attacks against critical infrastructure, and at public
gathering places for a range of attacks, including potential suicide operations and the release of
biological agents.

The Intelligence Community will continue assessments throughout the threat period and will
disseminate updates as circumstances indicate.

Finally, a Mission Folder detailing the recommended course of action for all Public Safety
Agencies in the state is currently under development. In the interim, the following considerations
are recommended.

Readiness Considerations: Public Health

Past intelligence, including an assessment of trends and potentials, demonstrates a desire of terrorists to
employ biological agents, toxins, chemical agents and radiological means (e.g., radiation dispersal
devices). Public health personnel should raise their index of suspicion for medical conditions, which may
result from bioagents. Healthcare facilities and providers are encouraged to coordinate with and report
cases to your County Department of Health Services.

In addition, medical and health personnel should contact local law enforcement or the FBI to
report any terrorist activity or other suspicious circumstances or request assistance regarding
threat assessment.

This assessment is Public Safety Sensitive. Distribution is authorized to public officials, public safety
and public health and healthcare personnel, including incident command personnel. Distribution or
further dissemination beyond those agencies is not authorized.
41
CA Statewide Medical & Health
Disaster Exercise
PUBLIC SAFETY SENSITIVE // NOT FOR PUBLIC DISSEMINATION
THIS IS AN EXERCISE
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

Master Sequence of Events

Lists

42
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
ACUTE CARE HOSPITALS

Real Scenario Message Receiving Information Acute Care Hospitals Message/Event Anticipated
Time Time Event # Officer Source Response
Pre-Event Discussion Points:
o How would your organization (hospital, clinic, EMS
provider, or local public health department) be
notified of security alerts and/or credible threats to
healthcare infrastructure and who would the
information come from?
o What internal processes or procedures do you have
to communicate sensitive information on a “need to
know” basis? To whom would the information be
communicated to in your organization?
Pre- o When the Federal Homeland Security Threat Level is
Event raised from Orange to Red, are there any activities
that would be activated, including increased security
measures? What internal and external notifications
are activated?
o What other agencies or organizations would it be
imperative to make contact with and discuss
protection of your critical infrastructure?
o What other opportunities, issues, and challenges do
you identify given this chain of events and in light of
the elevation of the Homeland Security Threat Level
to Red?
October 25, 2007 – The Exercise Begins
Who are the key people who can make the decision to
0500
activate the HCC?
Once the decision is made to activate the HCC, what is
0500 the alert and notification process and what personnel are
notified?
What key positions in the HCC incident management
0500
team should be activated and why?
0500 What other agencies or organizations would you

43
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
ACUTE CARE HOSPITALS

Real Scenario Message Receiving Information Acute Care Hospitals Message/Event Anticipated
Time Time Event # Officer Source Response
consider notifying of the HCC activation? Who makes
those notifications?
Who determines activation of the high census plan or
0700 procedures to free up or add patient beds to
accommodate a large number of critical admissions?
What strategies can be implemented to enhance
0700
emergency department capacity?
With the supply of ventilators severely limited, what
0700 strategies can be implemented to procure additional
ventilators?
How will the assessment of priority for current and future
0700 use of ventilators be managed in the hospital? Who will
make the prioritization and use decisions?
Will the hospital alter the process of regularly scheduled
appointments or non-emergency admissions at this
0700
time? How will information be communicated to patients
that may be affected by any changes?
What epidemiology/infection control issues have been
0700 (or should have been) identified and should be reported
to the local public health department?
What are the processes and mechanisms to notify the
0700
local public health department of the outbreak?
What potential challenges/issues may the hospital face
0700 in the next 4 hours and what actions can be taken to
mitigate or correct the issues?
Within the hospital incident management team, are there
O700 medical or technical specialists who could assist in
decision making?
What additional security measures can be implemented
0800
to enhance hospital security?

44
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
ACUTE CARE HOSPITALS

Real Scenario Message Receiving Information Acute Care Hospitals Message/Event Anticipated
Time Time Event # Officer Source Response
Should the hospital consider screening of all persons
0800 entering the hospital? If initiated, how will this be
communicated to EMS and ambulance providers?
What PPE should be considered for security staff and
staff assigned to monitor entrances (e.g., lobby)? How
0800
do you ensure assigned staff have appropriate PPE
training?
What is the procedure for reporting suspect cases to the
0800
local public health department?
How do you prioritize and triage patient care during a
patient surge event, continue to maintain community
0800
care and regular appointments, while accommodating
the infectious patients?
What is the appropriate process to ascertain current bed
counts and patient census to report to the local public
0800 health department? What are the appropriate forms that
should be used and how is the information
communicated?
How will you respond to the concerns and information
0930 needs of the on and off-duty staff, patients, and visitors
who are monitoring the news broadcasts?
How will essential services be determined and provided
0930 in light or increased patient numbers and decreased
staffing?
Has your Public Information Officer/public affairs
0930
department been activated?

45
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
ACUTE CARE HOSPITALS

Real Scenario Message Receiving Information Acute Care Hospitals Message/Event Anticipated
Time Time Event # Officer Source Response
The PIO must prepare a press release in collaboration
with the JIC, local public health department, and local
0930
emergency management. What is your facility policy for
the release of information and media briefings?
What issues does law enforcement interviewing patients
0930 and staff pose to the healthcare facility, staff, patients,
local public health, and others?
What policies and procedures are in place to guide and
0930 direct staff when dealing with law enforcement requests?
What facility policies guide evidence collection in a
terrorism event and law enforcement confiscation of
0930
patient belongings, valuables, and other items for
evidence?
How will law enforcement personnel interviewing
patients be oriented to and provided with personal
0930 protective equipment? Are there additional precautions
that should be taken or required (e.g., limiting or denying
contact with infected patients)?
Who will control and coordinate the release of
0930 information, access to the patients, and release of
medical records?
How will the hospital deal with staff absenteeism issues?
0930 Are there procedures or plans in place to address the
issues?
How will the hospital/clinic deal with staff who insist on
0930
leaving work to avoid exposure?

46
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
ACUTE CARE HOSPITALS

Real Scenario Message Receiving Information Acute Care Hospitals Message/Event Anticipated
Time Time Event # Officer Source Response
How does the hospital and/or clinic assess, triage, and
determine the allocation of scarce resources including
0930
acute care beds, ventilators, and equipment? How are
staff on-duty notified of these changes?
Local law enforcement will be arriving to the facility to
interview patients and others. What patient information
0930 and medical records can be released to FBI/law
enforcement, in accordance with patient privacy and
statutes?
All participants conduct a media briefing/press
conference.
o Who will be the spokesperson(s) for the hospital?
o How will pre-briefing planning be coordinated with
health care and emergency management
partners?
0945 o Where will the media briefing be conducted?
o Who should attend the media briefing in addition
to the spokespersons?
o What information will be provided to the media?
o How will the agency conducting the media
briefing ensure the information is consistent with
other response partners?

47
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
ACUTE CARE HOSPITALS

Real Scenario Message Receiving Information Acute Care Hospitals Message/Event Anticipated
Time Time Event # Officer Source Response
In consultation with the engineering department,
infection control, and the Incident
Commander/Operations Section Chief and/or Director or
VP of Nursing, where should the designated isolation
1000 area be established?
o Patient care area
o Conversion of a non-acute patient care area
o Isolating patients in alternate care site outside of
the hospital facility
How can the Heating, Ventilation and Air Conditioning
1000 (HVAC) be controlled in the designated area to ensure
respiratory isolation?
How will the hospital/clinic deal with staff that insist on
0930
leaving work to avoid exposure?
How does the hospital and/or clinic assess, triage, and
determine the allocation of scarce resources including
0930
acute care beds, ventilators, and equipment? How are
staff on-duty notified of these changes?
Local law enforcement will be arriving to the facility to
interview patients and others. What patient information
0930 and medical records can be released to FBI/law
enforcement, in accordance with patient privacy and
statutes?
0945 Who will be the media spokesperson(s) for the hospital?
0945 Where should the media briefing be conducted?
Who should attend the briefing in addition to the
0945
spokespersons?
0945 What information will be provided to the media?

48
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
ACUTE CARE HOSPITALS

Real Scenario Message Receiving Information Acute Care Hospitals Message/Event Anticipated
Time Time Event # Officer Source Response
How will the agency conducting the media briefing
0945 ensure the provision of information that is consistent with
other response partners?
In consultation with the engineering department,
infection control, and the Incident
Commander/Operations Section Chief and/or Director or
VP of Nursing, where should the designated isolation
1000 area be established?
o Patient care area
o Conversion of a non-acute patient care area
o Isolating patients in alternate care site outside of
the hospital facility
How can the Heating, Ventilation and Air Conditioning
1000 (HVAC) be controlled in the designated area to ensure
respiratory isolation?

49
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
ACUTE CARE HOSPITALS

Acute Care Hospitals Message/Event

Real Scenario Message Receiving Information Anticipated
Time Time Event # Officer Source Response
What special considerations should be taken for the
designated isolation area?
o Security
o Staff assignment and protection
o Traffic flow and restriction of personnel, families
and friends
o Morgue
o Supplies and equipment, including PPE
1000
o Medical gases
o Nutritional Services
o Suctioning
o Air exchanges
o Biohazardous waste
o Suctioning
o Air exchanges
o Biohazardous waste
What additional resources or supplies (e.g., diapers,
1000 formula, cribs, and pediatric-sized respiratory
equipment) does the facility have to care for children?
How will you provide competent pediatric staff to care for
1000
the children presenting and admitted to the facility?
Does the facility have a plan to deal with children that
1000 are not sick or do not need to be admitted and arrive
with their parent that needs to be admitted?
Security of the facility staff, current patients, and the
facility is important. What security measures should be
1000
taken to protect the assets? Limited access?
Lockdown?

50
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
ACUTE CARE HOSPITALS

Real Scenario Message Receiving Information Acute Care Hospitals Message/Event Anticipated
Time Time Event # Officer Source Response
How will you orchestrate the security measures which
1000
will be implemented, and what processes will you use?
How will you communicate the security precautions and
1000
measures to the arriving public?
The public knows the hospital has medications to treat
the disease. How will you ensure the safety and security
1000
of the stockpiled equipment, supplies, and
pharmaceuticals?
How will you coordinate with clinics and private
1000 physicians to control or reduce transfers to your
hospital?
The hospital is receiving a large volume of calls for
1000 information and services. Is your organization able to
receive and process the calls?
What are your facility’s current par/stockpile levels of
1130 medications to treat the primary and secondary
infections?
What is the current stockpile/availability of medications
1130 in liquid form or in pediatric dosages to administer to
pediatric patients?
Yersinia pestis has been confirmed as the infectious
1130 agent. What appropriate isolation precautions should be
implemented?

51
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
ACUTE CARE HOSPITALS

Real Scenario Message Receiving Information Acute Care Hospitals Message/Event Anticipated
Time Time Event # Officer Source Response
How will you prioritize and allocate the use of the
medications?
o For current patients (symptomatic)?
1130 o For exposed but asymptomatic staff?
o As prophylaxis for staff at high risk for exposure
(e.g., caring for infected patients, ED staff)?
o For staff members families?
Does you hospital emergency operations plan address
the implementation of altered standards of care during a
surge event?
o How and by whom will the decision be made to
implement altered standards of care?
1130 o What criteria would be utilized for altering
standards of care?
o How will you triage and prioritize the use of
existing ventilators?
o How will implementation of altered standards of
care be tracked and evaluated?

52
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
ACUTE CARE HOSPITALS

Real Scenario Message Receiving Information Acute Care Hospitals Message/Event Anticipated
Time Time Event # Officer Source Response
You must now establish hospital-based alternate care
sites/alternate patient care locations to accommodate
the surge of patients.
o What logistical and staffing issues does this
present to the facility?
o How will patients be triaged and moved to the
alternate care site?
o Weather conditions must be taken into account in
1130 the establishment of alternate care sites. How
will this impact the plans?
o What is your procedure for notifying local CDPH
Licensing and Certification offices about the
plans to establish alternate care sites?
o Are there other waivers that might be needed
and requested from CDPH Licensing and
Certification? (e.g., waiver of nurse/staffing
ratios)
What additional space and resources can be procured
from outside of your facility to provide patient care and
1130 accommodate the surge? Are there any memorandums
of understanding (MOUs) that could be activated to
assist?
What are the procedures to communicate resource
1130 needs when you facility has or will soon exhaust current
supplies?
How will you track patients throughout the hospital,
including the hospital-based alternate care sites and to
1130
other patient care destinations, in accordance with
applicable law and regulations?

53
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
ACUTE CARE HOSPITALS

Real Scenario Message Receiving Information Acute Care Hospitals Message/Event Anticipated
Time Time Event # Officer Source Response
What communication and status reports are you
1130 maintaining with vendors of equipment, supplies, and
outside services (e.g., linen, food)?
Would the hospital consider providing prophylaxis to
1130
vendors and suppliers to ensure business continuity?
What communication and status reports are you
1130
providing to OA medical and health point of contact?
How will the following local public health decisions and
actions impact healthcare provider staffing and what
mitigation efforts can be undertaken?
o School dismissals/closures, in conjunction with
1130
the local Dept of Education?
o Social distancing, including closure of public
events and public gathering sites?
o Closure of child and adult day care centers?
1130 How are you tracking potential employee exposures?
The hospital may be contacted by local law enforcement
for names of patients presenting with symptoms or
1130 history of exposure. What is the hospital policy and
procedure(s) on releasing patient information to law
enforcement?
What can be done to immediately address the concerns
1200
of staff?
1200 How can personnel be augmented?
How will personal protective equipment be allocated
1200
among staff, physicians, and volunteers?
What other resources are available to your hospital lab
1200
to assist with specimen processing?

54
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
ACUTE CARE HOSPITALS

Real Scenario Message Receiving Information Acute Care Hospitals Message/Event Anticipated
Time Time Event # Officer Source Response
How will you expand isolation capacity within the facility
1200 to accommodate the large numbers of infected or
potentially infected patients?
Your morgue capacity is limited, and there have been 25
deaths. What provisions for storage, security, and
1200
evidence preservation of the bodies must be
implemented?
What provisions do you have for “just in time” fit testing
1200
and training for PPE?
Has a triage area and processes been established to
1200 immediately identify and isolate patients presenting with
suspicious symptoms from the general population?
Has triage, support, and education been established for
1200 asymptomatic/unexposed persons presenting to the ED,
clinics, medical offices and calling EMS providers?
Statistics for the Operational Area (county):
o Number of patients admitted with possible
pneumonic plague:
o Number of patients treated and triaged to home with
symptomatic care, including mild symptoms, the
1230 asymptomatic/unexposed (e.g., worried well) and
pre-symptomatic patients:
o Number of patients waiting to be seen:
o Estimated number of persons requiring mass
prophylaxis:
o Number of deceased:
How do you identify patients seen in previous days
1230
before the biological agent was identified?
How do you identify, monitor, and provide follow up to
1230
exposed staff?

55
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
ACUTE CARE HOSPITALS

Real Scenario Message Receiving Information Acute Care Hospitals Message/Event Anticipated
Time Time Event # Officer Source Response
Who within your community/OA can provide your
1230 organization with the information and recommendations
requested above?
Does your facility/service have a plan and procedures to
1230 manage and utilize convergent volunteers who present
to assist?
o The intensive care unit(s) within the hospital are at
capacity and there are no additional Intensive Care
Unit (ICU) beds.
o The emergency department (ED) is holding a
1330 number (insert appropriate number of ED
patients to increase strain on resources) of patients
awaiting inpatient beds, including ICU, telemetry,
medical surgical, and negative pressure isolation
rooms.
1330 What is the current situation status of the facility/service?
1330 What are the critical issues and resources?
What are the operational objectives for the operational
1330
period of 3:30 pm until 11:00 pm?
1330 What staffing is needed?
How are limited resources being allocated and
1330 prioritized? Who makes these decisions and how are
they conveyed to the staff and community?
1330 How will the facility be staffed?
How will the Hospital Command Center/Emergency
1330 Operations Center/Department Operations Center be
staffed? Can any positions be demobilized?
What community “volunteer” resources can be utilized by
1330 your facility to assist with the surge of patients which are
expected to continue for an extended period of time?

56
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
ACUTE CARE HOSPITALS

Real Scenario Message Receiving Information Acute Care Hospitals Message/Event Anticipated
Time Time Event # Officer Source Response
How will you address the behavioral health/psychosocial
needs of the staff, volunteers, physicians, and patients,
1330
including Critical Incident Stress Management/Debriefing
(CISM/D)?
How will your facility or service ensure business
continuity, maintenance of those essential or critical
1330
services, and continue to provide community care
services?
How will your facility deal with the substantial increase in
1330 sanitation needs, demand for food/drink, and patient
holding areas due to the patient surge?
DEVELOP AN INCIDENT ACTION PLAN
What other organizations or responders could/should
also receive the Incident Action Plan (IAP) to facilitate
communication and response among partners?
How will you communicate the IAP to the appropriate
1330
agencies?
From which agencies would it be helpful to receive their
1330
IAPs?
EXECUTE A SHIFT CHANGE
o Conduct an incident briefing and report of current
situation status
o Announce a formal transfer of command
1500 o Report the Incident Action Plan for the next
operational period
o Replace off going personnel with oncoming
personnel (or simulate a change of positions in the
command centers)

57
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
ACUTE CARE HOSPITALS

Real Scenario Message Receiving Information Acute Care Hospitals Message/Event Anticipated
Time Time Event # Officer Source Response
CONDUCT A PRESS CONFERENCE AT 1630
o What community or governmental agencies should
participate in the press conferences (e.g., public
health department, healthcare facility officials, local
government, and physicians)?
o Who is the most appropriate person(s) to represent
the healthcare facility at the press conference(s) and
who makes this decision?
o How often should the press conferences be
1600 scheduled?
o Where should the press conferences be convened
within the community?
o Who is the “lead” agency for the press conferences?
o What steps have been taken to ensure a consistent
message among the healthcare community and all
levels of government agencies/officials? Who makes
the final decision about information to be conveyed
when there is conflict among the responding
agencies?
LONG TERM PLANNING/RECOVERY
Activate current processes and procedures to procure
essential resources needed currently and the next 24
1630
hours. If no processes or procedures exist, what
possible actions and plans can be taken to procure the
resources?
Can vendors be protected from exposure or provided
1630
prophylaxis to ensure delivery of needed resources?

58
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
ACUTE CARE HOSPITALS

Real Scenario Message Receiving Information Acute Care Hospitals Message/Event Anticipated
Time Time Event # Officer Source Response
What resources and mechanisms are available to
procure the needed supplies and equipment and who or
what agency is contacted to provide those resources?
o Intra-hospital resources
1630
o Inter-hospital resources
o Community resources, including city and county
o County resources, including the MHOAC in the EOC
o Others
What are the proper channels of communication and
1630 who or what agency is contacted to obtain those
resources?
What non-medical resources may be needed in the
1630 event (e.g., security, law enforcement, sanitation, water,
transportation)?
How will you maintain evidence/chain of custody for the
1630 dead bodies resulting from the bioterrorism/mass
casualty event?
What non-medical resources may be needed in the
1630 event (e.g., security, law enforcement, sanitation, water,
transportation)?
1645 Report hospital status to the MHOAC/OA EOC.
THE EXERCISE ENDS
Conduct an exercise debriefing with HCC and
departmental staff immediately upon termination of the
exercise.
1700 Post exercise activities may include:
o Formal debriefing and incident review session with
key personnel and the Emergency Preparedness
Committee.
o Development of an After-Action Report (AAR).

59
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
ACUTE CARE HOSPITALS
o Development of a Corrective Action Plan (CAP),
including timelines and deadlines for improvements.
o Dissemination of the AAR and CAP to key internal
and external stakeholders.
o Planning for the next exercise.

60
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
COMMUNITY CLINICS

Real Scenario Message Receiving Information Community Clinics Message/Event Anticipated

Time Time Event # Officer Source Response
Pre-Event Discussion Points:
o How would your clinic be notified of security alerts
and/or credible threats to healthcare infrastructure
and who would the information come from?
o What internal processes or procedures do you have
to communicate sensitive information on a “need to
know” basis? To whom would the information be
communicated to in your organization?
o When the Federal Homeland Security Threat Level is
Pre- raised from Orange to Red, are there any activities
Event that would be activated, including increased security
measures? What internal and external notifications
are activated?
o What other agencies or organizations would it be
imperative to make connections with and discuss
protection of your critical infrastructure?
o What other opportunities, issues, and challenges do
you identify given this chain of events and in light of
the elevation of the Homeland Security Threat Level
to Red?
October 25, 2007 – The Exercise Begins
How do you prioritize and triage patient care during a
patient surge event, maintaining community care and
0900
regular appointments, while accommodating the
infectious patients?
What is the trigger to cancel or reschedule routine clinic
0900
appointment to accommodate the surge of ILI patients?
How will the rescheduling of routine appointments
0900
impact these patients and their continuity of care?

61
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
COMMUNITY CLINICS

Real Scenario Message Receiving Information Community Clinics Message/Event Anticipated

Time Time Event # Officer Source Response
What infection control measures for staff and patients
0900
should be implemented?
Does your plan include isolating patients with ILI from
0900
the general clinic population to decrease exposure?
How will you respond to the concerns and information
0930
needs of the on and off-duty staff, patients, and visitors
who are monitoring the news broadcasts?
How will essential services be determined and provided
0930 in light or increased patient numbers and decreased
staffing?
Has your Public Information Officer/public affairs
0930
department been activated?
The PIO must prepare a press release in collaboration
with the JIC, local public health department, and local
0930
emergency management. What is your facility policy for
the release of information and media briefings?
What issues does law enforcement interviewing patients
0930 and staff pose to the healthcare facility, staff, patients,
local public health, and others?
What policies and procedures are in place to guide and
0930
direct staff when dealing with law enforcement requests?
What facility policies guide evidence collection in a
terrorism event and law enforcement confiscation of
0930
patient belongings, valuables, and other items for
evidence?

62
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
COMMUNITY CLINICS

Real Scenario Message Receiving Information Community Clinics Message/Event Anticipated

Time Time Event # Officer Source Response
How will law enforcement personnel interviewing
patients be oriented to and provided with personal
0930 protective equipment? Are there additional precautions
that should be taken or required (e.g., limiting or denying
contact with infected patients)?
Who will control and coordinate the release of
0930 information, access to the patients, and release of
medical records?
How will the clinic deal with staff absenteeism issues?
Are there procedures or plans in place to address the
0930 issues?
How will the clinic deal with staff who insist on leaving
work to avoid exposure?
How does the clinic assess, triage, and determine the
allocation of scarce resources including acute care beds,
0930
ventilators, and equipment? How are staff on-duty
notified of these changes?
Local law enforcement will be arriving to the facility to
interview patients and others. What patient information
0930 and medical records can be released to FBI/law
enforcement, in accordance with patient privacy and
statutes?

63
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
COMMUNITY CLINICS

Real Scenario Message Receiving Information Community Clinics Message/Event Anticipated

Time Time Event # Officer Source Response
All participants conduct a media briefing/press
conference.
o Who will be the spokesperson(s) for the clinic?
o How will pre-briefing planning be coordinated with
health care and emergency management
partners?
0945 o Where will the media briefing be conducted?
o Who should attend the media briefing in addition
to the spokespersons?
o What information will be provided to the media?
o How will the agency conducting the media briefing
ensure the information is consistent with other
response partners?
Security of the facility staff, current patients, and the
facility is important. What security measures should be
1000
taken to protect the assets? Limited access?
Lockdown?
How will you orchestrate the security measures which
1000
will be implemented, and what processes will you use?
How will you communicate the security precautions and
1000
measures to the arriving public?
Yersinia pestis has been confirmed as the infectious
1000 agent. What appropriate isolation precautions should be
implemented?
The public knows the hospital/clinic has medications to
treat the disease. How will you ensure the safety and
1000
security of the stockpiled equipment, supplies, and
pharmaceuticals?

64
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
COMMUNITY CLINICS

Real Scenario Message Receiving Information Community Clinics Message/Event Anticipated

Time Time Event # Officer Source Response
How will you coordinate with clinics and private
1000
physicians to control or reduce transfers to the hospital?
The hospital/clinic is receiving a large volume of calls for
1000 information and services. Is your organization able to
receive and process the calls?
Your clinic’s current in-house supply of
treatment/prophylaxis medications is severely limited, if
1130
available at all. How will you provide prophylaxis to
staff?
Patients seen in the clinics are given prescriptions for
the medications to treat minor symptoms or as
prophylaxis for exposures. The patients are returning to
1130 the clinics very angry because local pharmacies have
run out of the medications and they cannot fill their
prescriptions. What strategies will address these
issues?
What additional space and resources can be procured
from outside of your facility to provide patient care and
1130 accommodate the surge? Are there any memorandums
of understanding (MOUs) that could be activated to
assist?
What communication and status reports are you
1130 maintaining with vendors of equipment, supplies and
outside services (e.g., linen)?
Would the clinic consider providing prophylaxis to
1130
vendors and suppliers to ensure business continuity?
What communication and status reports are you
1130
providing to OA medical and health point of contact?
1130 How are you tracking potential employee exposures?

65
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
COMMUNITY CLINICS

Real Scenario Message Receiving Information Community Clinics Message/Event Anticipated

Time Time Event # Officer Source Response
What actions should be considered by the clinic in light
1200 of the overwhelming patient volumes, patient needs, lack
of resources, and exhausted staff?
What are your options and processes to acquire
1200
additional equipment, supplies, and pharmaceuticals?
How will you respond to the concerns and information
needs of the staff, patients, and visitors who are
1200
monitoring the news broadcasts? What messages
should be developed to address their needs?
How can you augment personnel and staffing of the
1200
clinic?
How will you manage the deceased? Storage, security,
1200
and evidence preservation?
Statistics for the Operational Area (county):
o Number of patients admitted with possible
pneumonic plague:
o Number of patients treated and triaged to home with
symptomatic care, including mild symptoms, the
1230 asymptomatic/unexposed (e.g., worried well) and
pre-symptomatic patients:
o Number of patients waiting to be seen:
o Estimated number of persons requiring mass
prophylaxis:
o Number of deceased:
How do you identify patients seen in previous days
1230
before the biological agent was identified?
How do you identify, monitor, and provide follow up to
1230
exposed staff?

66
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
COMMUNITY CLINICS

Real Scenario Message Receiving Information Community Clinics Message/Event Anticipated

Time Time Event # Officer Source Response
Who within your community/OA can provide your
1230 organization with the information and recommendations
requested above?
Does your facility/service have a plan and procedures to
1230 manage and utilize convergent volunteers who present
to assist?
1330 What is the current situation status of the clinic?
1330 What are the critical issues and resources?
What are the operational objectives for the operational
1330
period of 3:30 pm until 11:00 pm?
1330 What staffing is needed?
How are limited resources being allocated and
1330 prioritized? Who makes these decisions and how are
they conveyed to the staff and community?
1330 How will the facility be staffed?
How will the clinic Emergency Operations Center be
1330
staffed? Can any positions be demobilized?
What community “volunteer” resources can be utilized by
1330 your facility to assist with the surge of patients which are
expected to continue for an extended period of time?
How will you address the behavioral health/psychosocial
needs of the staff, volunteers, physicians, and patients,
1330
including Critical Incident Stress Management/Debriefing
(CISM/D)?
How will your facility or service ensure business
continuity, maintenance of those essential or critical
1330
services, and continue to provide community care
services?

67
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
COMMUNITY CLINICS

Real Scenario Message Receiving Information Community Clinics Message/Event Anticipated

Time Time Event # Officer Source Response
How will your facility deal with the substantial increase in
sanitation needs, demand for food/drink, and patient
1330
holding areas due to the patient surge?

DEVELOP AN INCIDENT ACTION PLAN

What other organizations or responders could/should
1330
also receive the Incident Action Plan (IAP) to facilitate
communication and response among partners?
How will you communicate the IAP to the appropriate
1330
agencies?
From which agencies would it be helpful to receive their
IAPs?
EXECUTE A SHIFT CHANGE
o Conduct an incident briefing and report of current
situation status
o Announce a formal transfer of command
1500 o Report the Incident Action Plan for the next
operational period
o Replace off going personnel with oncoming
personnel (or simulate a change of positions in the
command centers)
What community or governmental agencies should
participate in the press conferences (e.g., public health
1600
department, healthcare facility officials, local
government, and physicians)?
Who is the most appropriate person(s) to represent the
1600 healthcare facility at the press conference(s) and who
makes this decision?
1600 How often should the press conferences be scheduled?

68
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
COMMUNITY CLINICS

Real Scenario Message Receiving Information Community Clinics Message/Event Anticipated

Time Time Event # Officer Source Response
Where should the press conferences be convened within
1600
the community?
1600 Who is the “lead” agency for the press conferences?
What steps have been taken to ensure a consistent
message among the healthcare community and all levels
1600 of government agencies/officials? Who makes the final
decision about information to be conveyed when there is
conflict among the responding agencies?
LONG TERM PLANNING/RECOVERY
Activate current processes and procedures to procure
essential resources needed currently and the next 24
1630
hours. If no processes or procedures exist, what
possible actions and plans can be taken to procure the
resources?
Can vendors be protected from exposure or provided
1630
prophylaxis to ensure delivery of needed resources?
What resources and mechanisms are available to
procure the needed supplies and equipment and who or
what agency is contacted to provide those resources?
o Intra-clinic resources
1630 o Inter-clinic resources
o Community resources, including city and county
o County resources, including the MHOAC in the
EOC
o Others
What are the proper channels of communication and
1630 who or what agency is contacted to obtain those
resources?

69
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
COMMUNITY CLINICS

Real Scenario Message Receiving Information Community Clinics Message/Event Anticipated

Time Time Event # Officer Source Response
What non-medical resources may be needed in the
1630 event (e.g., security, law enforcement, sanitation, water,
transportation)?
How will you maintain evidence/chain of custody for the
1630 dead bodies resulting from the bioterrorism/mass
casualty event?
What non-medical resources may be needed in the
1630 event? (e.g., security, law enforcement, sanitation,
water, transportation)
1645 Report clinic status to the MHOAC/OA EOC.
THE EXERCISE ENDS
Conduct an exercise debriefing with HCC and
departmental staff immediately upon termination of the
exercise.

Post exercise activities may include:

o Formal debriefing and incident review session with
1700 key personnel and the Emergency Preparedness
Committee.
o Development of an After-Action Report (AAR).
o Development of a Corrective Action Plan (CAP),
including timelines and deadlines for improvements.
o Dissemination of the AAR and CAP to key internal
and external stakeholders.
o Planning for the next exercise.

70
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
EMS PROVIDERS

Real Scenario Message Receiving Information EMS Providers Message/Event Anticipated

Time Time Event # Officer Source Response
Pre-Event Discussion Points:
o How would your organization (clinic, EMS provider,
or local public health department) be notified of
security alerts and/or credible threats to healthcare
infrastructure and who would the information come
from?
o What internal processes or procedures do you have
to communicate sensitive information on a “need to
know” basis? To whom would the information be
communicated to in your organization?
Pre- o When the Federal Homeland Security Threat Level is
Event raised from Orange to Red, are there any activities
that would be activated, including increased security
measures? What internal and external notifications
are activated?
o What other agencies or organizations would it be
imperative to make connections with and discuss
protection of your critical infrastructure?
o What other opportunities, issues, and challenges do
you identify given this chain of events and in light of
the elevation of the Homeland Security Threat Level
to Red?
October 25, 2007 – The Exercise Begins
What are the triggers/criteria/considerations for
0700 enhancing staffing to put more ambulances in service to
meet the 911 call volume demands?
With an increased number of 911 patients with severe
cough and ILI, what increased personal
0700
protective/infection control measures should be
recommended to EMS crews?

71
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
EMS PROVIDERS

Real Scenario Message Receiving Information EMS Providers Message/Event Anticipated

Time Time Event # Officer Source Response
What potential challenges/issues may the EMS
0700 personnel face in the next 4 hours and what actions can
be taken to mitigate or correct the issues?
Is there a policy / procedure in place to relax transport
0700 guidelines and response times? What triggers this
policy?
How will you respond to the concerns and information
0930 needs of the on and off-duty staff, patients, and visitors
who are monitoring the news broadcasts?
How will essential services be determined and provided
0930 in light or increased patient numbers and decreased
staffing?
Has your Public Information Officer/public affairs
0930
department been activated?
The PIO must prepare a press release in collaboration
with the JIC, local public health department, and local
0930
emergency management. What is your facility policy for
the release of information and media briefings?
What issues does law enforcement interviewing patients
0930 and staff pose to the healthcare facility, staff, patients,
local public health, and others?
What policies and procedures are in place to guide and
0930
direct staff when dealing with law enforcement requests?
What facility policies guide evidence collection in a
terrorism event and law enforcement confiscation of
0930
patient belongings, valuables, and other items for
evidence?

72
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
EMS PROVIDERS

Real Scenario Message Receiving Information EMS Providers Message/Event Anticipated

Time Time Event # Officer Source Response
How will law enforcement personnel interviewing
patients be oriented to and provided with personal
0930 protective equipment? Are there additional precautions
that should be taken or required (e.g., limiting or denying
contact with infected patients)?
Who will control and coordinate the release of
0930 information, access to the patients, and release of
medical records?
All participants conduct a media briefing/press
conference.
o Who will be the spokesperson(s) for the hospital?
o How will pre-briefing planning be coordinated with
health care and emergency management
partners?
0945 o Where will the media briefing be conducted?
o Who should attend the media briefing in addition
to the spokespersons?
o What information will be provided to the media?
o How will the agency conducting the media briefing
ensure the information is consistent with other
response partners?
What procedures currently exist or must be implemented
1000
to decontaminate the ambulances between transports?
What measures have been taken to protect the staff
1000
during patient assessment and transport?

73
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
EMS PROVIDERS

Real Scenario Message Receiving Information EMS Providers Message/Event Anticipated

Time Time Event # Officer Source Response
Are alternate care sites available for EMS/ambulances to
transport non-acute patients to instead of the acute care
1000
facility? How would you be notified that alternate care
sites have opened?
What permissions or changes in protocols would be
necessary for ambulances to transport appropriate
patients to alternate care sites or clinics instead of the
1000
acute care hospital? Who would sanction alternate
destinations and provide guidelines to you (e.g., local
EMS agency, local health department/officer)?
Has mass prophylaxis for the staff been arranged, and
1000
how is this information provided to the staff?
What measures have been taken to increase staffing
1000 and the numbers of available ambulance units in service
to accommodate the surge of patients?
What infection control precautions have been taken for
1200
EMS/ambulance personnel?
Who has the authority to establish altered triage and
1200 dispatch priorities to ensure ambulances are dispatched
appropriately?
What other EMS/ambulance resources (e.g., additional
1200
rigs and staff) are available to you?
What is the decision-making process to make an ALS
1200 staffed rig into a BLS staffed rig in order to increase the
number of ambulances available?

74
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
EMS PROVIDERS

Real Scenario Message Receiving Information EMS Providers Message/Event Anticipated

Time Time Event # Officer Source Response
What medications and supplies are severely limited?
What is the process of re-supplying critical equipment
1200
and supplies if hospitals and vendors cannot provide
resources through normal supply chains?
What are the decision-making processes to determine
1200
altered standards of care for EMS patients?
How do you identify patients transported in previous
1230
days before the biological agent was identified?
How do you identify, monitor, and provide follow up to
1230
exposed staff?
Who within your community/OA can provide your
1230 organization with the information and recommendations
requested above?
Does your facility/service have a plan and procedures to
1230 manage and utilize convergent volunteers who present
to assist?
1330 What is the current situation status of the EMS service?
1330 What are the critical issues and resources?
What are the operational objectives for the operational
1330
period of 3:30 pm until 11:00 pm?
1330 What staffing is needed?
How are limited resources being allocated and
1330 prioritized? Who makes these decisions and how are
they conveyed to the staff and community?
1330 How will the EMS service be staffed?
How will the Department Operations Center be staffed?
1330
Can any positions be demobilized?

75
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
EMS PROVIDERS

Real Scenario Message Receiving Information EMS Providers Message/Event Anticipated

Time Time Event # Officer Source Response
What community “volunteer” resources can be utilized by
1330 your facility to assist with the surge of patients which are
expected to continue for an extended period of time?
How will you address the behavioral health/psychosocial
needs of the staff, volunteers, physicians, and patients,
1330
including Critical Incident Stress Management/Debriefing
(CISM/D)?
How will your facility or service ensure business
continuity, maintenance of those essential or critical
1330
services, and continue to provide community care
services?
How will your facility deal with the substantial increase in
1330 sanitation needs, demand for food/drink, and patient
holding areas due to the patient surge?
DEVELOP AN INCIDENT ACTION PLAN
What other organizations or responders could/should
1330
also receive the Incident Action Plan (IAP) to facilitate
communication and response among partners?
How will you communicate the IAP to the appropriate
1330
agencies?
From which agencies would it be helpful to receive
1330
their IAPs?
EXECUTE A SHIFT CHANGE
Conduct an incident briefing and report of current
situation status
1500
o Announce a formal transfer of command
o Report the Incident Action Plan for the next
operational period

76
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
EMS PROVIDERS

Real Scenario Message Receiving Information EMS Providers Message/Event Anticipated

Time Time Event # Officer Source Response
o Replace off going personnel with oncoming
personnel (or simulate a change of positions in the
command centers)
Conduct a Press Conference
o What community or governmental agencies should
participate in the press conferences (e.g., public
health department, healthcare facility officials, local
government, and physicians)?
o Who is the most appropriate person(s) to represent
1600 the EMS providers at the press conference(s) and
who makes this decision?
o How often should the press conferences be
scheduled?
o Where will the press conferences be convened
within the community?
1600 o Who is the “lead” agency for the press conferences?
o What steps have been taken to ensure a consistent
message among the healthcare community and all
levels of government agencies/officials?
o Who makes the final decision about information to be
conveyed when there is conflict among the
responding agencies?
LONG TERM PLANNING/RECOVERY
Activate current processes and procedures to procure
1630
essential resources needed currently and the next 24
hours.
If no processes or procedures exist, what possible
1630 actions and plans can be taken to procure the
resources?

77
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
EMS PROVIDERS

Real Scenario Message Receiving Information EMS Providers Message/Event Anticipated

Time Time Event # Officer Source Response
Can vendors be protected from exposure or provided
1630
prophylaxis to ensure delivery of needed resources?
What resources and mechanisms are available to
procure the needed supplies and equipment and who or
what agency is contacted to provide those resources?
o Intra-hospital resources
1630 o Inter-hospital resources
o Community resources, including city and county
o County resources, including the MHOAC in the
EOC
o Others
What are the proper channels of communication and
1630 who or what agency is contacted to obtain those
resources
What non-medical resources may be needed in the
1630 event? (e.g., security, law enforcement, sanitation,
water, transportation)
1645 Report EMS provider status to the MHOAC/OA EOC.
THE EXERCISE ENDS
Conduct an exercise debriefing with HCC and
departmental staff immediately upon termination of the
exercise.
1700
Post exercise activities may include:
o Formal debriefing and incident review session with
key personnel and the Emergency Preparedness
Committee.
o Development of an After-Action Report (AAR).

78
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
EMS PROVIDERS

Real Scenario Message Receiving Information EMS Providers Message/Event Anticipated

Time Time Event # Officer Source Response
o Development of a Corrective Action Plan (CAP),
including timelines and deadlines for improvements.
o Dissemination of the AAR and CAP to key internal
and external stakeholders.
o Planning for the next exercise.

79
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
LOCAL PUBLIC HEALTH DEPARTMENT

Real Scenario Message Receiving Information Local Public Health Department Message/Event Anticipated
Time Time Event # Officer Source Response
Pre-Event Discussion Points:
o How would your organization (hospital, clinic, EMS
provider, or local public health department) be
notified of security alerts and/or credible threats to
healthcare infrastructure and who would the
information come from?
o What internal processes or procedures do you have
to communicate sensitive information on a “need to
know” basis? To whom would the information be
communicated to in your organization?
Pre- o When the Federal Homeland Security Threat Level is
Event raised from Orange to Red, are there any activities
that would be activated, including increased security
measures? What internal and external notifications
are activated?
o What other agencies or organizations would it be
imperative to make connections with and discuss
protection of your critical infrastructure?
o What other opportunities, issues, and challenges do
you identify given this chain of events and in light of
the elevation of the Homeland Security Threat Level
to Red?
October 25, 2007 – The Exercise Begins
What epidemiological information or testing is needed
0800
from healthcare providers?
How will the appropriate laboratory testing requirements
0800
be communicated to the hospitals?

80
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
LOCAL PUBLIC HEALTH DEPARTMENT

Real Scenario Message Receiving Information Local Public Health Department Message/Event Anticipated
Time Time Event # Officer Source Response
How will the specimens be transported from the facilities
to the public health laboratory, in accordance with
0800
applicable laws and regulations? How is chain of
custody maintained in a large scale event?
How will public health staff be dispatched to hospitals to
conduct investigations? How many investigators are
0800
available for this and how long will it take to dispatch
them?
How will information about the outbreak be disseminated
0800 to healthcare providers, including non-hospital-based
providers?
What is the process for requesting hospitals to report
0800 bed counts and patient census, and what forms or
mechanism are used to report this information?
How will you respond to the concerns and information
0930 needs of the on and off-duty staff, patients, and visitors
who are monitoring the news broadcasts?
How will essential services be determined and provided
0930 in light or increased patient numbers and decreased
staffing?
Has your Public Information Officer/public affairs
0930
department been activated?
The PIO must prepare a press release in collaboration
with the JIC, local public health department, and local
0930
emergency management. What is your facility policy for
the release of information and media briefings?

81
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
LOCAL PUBLIC HEALTH DEPARTMENT

Real Scenario Message Receiving Information Local Public Health Department Message/Event Anticipated
Time Time Event # Officer Source Response
What issues does law enforcement interviewing patients
0930 and staff pose to the healthcare facility, staff, patients,
local public health, and others?
What policies and procedures are in place to guide and
0930
direct staff when dealing with law enforcement requests?
How will law enforcement personnel interviewing
patients be oriented to and provided with personal
0930 protective equipment? Are there additional precautions
that should be taken or required (e.g., limiting or denying
contact with infected patients)?
Who will control and coordinate the release of
0930 information, access to the patients, and release of
medical records?
All participants conduct a media briefing/press
conference.
o Who will be the spokesperson(s) for the hospital?
o How will pre-briefing planning be coordinated with
health care and emergency management
partners?
0945 o Where will the media briefing be conducted?
o Who should attend the media briefing in addition
to the spokespersons?
o What information will be provided to the media?
o How will the agency conducting the media briefing
ensure the information is consistent with other
response partners?

82
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
LOCAL PUBLIC HEALTH DEPARTMENT

Real Scenario Message Receiving Information Local Public Health Department Message/Event Anticipated
Time Time Event # Officer Source Response
Until the infectious agent is positively identified, what
actions, if any, can be taken by local public health to
1000
allay public anxiety and demonstrate government
action?
Given the possibility of a biological terrorism event,
1000 should the public health department begin to make
provision for the implementation of mass prophylaxis?
The public health department is receiving a large volume
1000 of calls for information and services. Is your
department(s) able to receive and process the calls?
The public knows the local health department has
medications to treat the disease. How will you ensure
1000
the safety and security of the stockpiled equipment,
supplies, and pharmaceuticals?
What community mitigation measures might you
1000 consider prior to the identification of the infectious
agent?

83
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
LOCAL PUBLIC HEALTH DEPARTMENT

Real Scenario Message Receiving Information Local Public Health Department Message/Event Anticipated
Time Time Event # Officer Source Response
With the confirmation of Yersinia pestis, mass
prophylaxis should be considered.
o What are the decision making processes for
activating mass prophylaxis plans and establishing
Points of Dispensing (POD) in the
community/county?
1130
o What staffing and logistical concerns does the
activation of PODs present to the local or State
health departments?
o Weather conditions must be taken into account in the
establishment of alternate care sites and/or PODS.
How will this impact the plans?
What is the process for requesting treatment/prophylaxis
medications and critical patient care supplies and
1130
equipment from regional, state, and/or Federal
resources?
What are the triggers to activate standing orders and
protocols, if they exist, for the implementation of mass
1130
prophylaxis? If they do not exist, what are the decision-
making processes to implement mass prophylaxis?
What recommendations will be provide to healthcare
providers about the prioritization and allocation of
prophylaxis medications?
o For current patients (symptomatic)?
1130
o For exposed but asymptomatic staff?
o As prophylaxis for staff at high risk for exposure
(e.g., caring for infected patients, ED staff)?
o For staff members families?

84
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
LOCAL PUBLIC HEALTH DEPARTMENT

Real Scenario Message Receiving Information Local Public Health Department Message/Event Anticipated
Time Time Event # Officer Source Response
How will the information about PODs be communicated
1130 to healthcare providers for patient referral and to the
public?
Once a local public health emergency is declared by the
health officer, how is this information disseminated to
1130
healthcare providers, government agencies, surrounding
OAs, the Region, the State, and the public?
1130 How are you tracking potential employee exposures?
Who makes the decision to open community-based
1130 alternate care sites and what other internal or externals
agencies should be involved in the decision?

85
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
LOCAL PUBLIC HEALTH DEPARTMENT

Real Scenario Message Receiving Information Local Public Health Department Message/Event Anticipated
Time Time Event # Officer Source Response
Additional community-based alternate care sites are
needed to meet the community surge of patients and
decompress the load on the acute care facilities in order
to maintain critical resources for the acutely ill. What
staffing and logistical challenges does the opening of
alternate care sites present to local public health?
o Should community alternate care sites be
established to meet the surge?
o How will you communicate the decision to open
or not to open community-based alternate care
1200 site(s)?
o If the alternate care sites are opened, what local
government entity can provide large quantities of
supplies and equipment?
o If supplies, equipment, and staffing resources are
not available locally, how will you obtain these
resources from other entities? Who is
responsible for contacting other agencies to
obtain the resources?
o What community resources are available to
support operation of the alternate care site(s)?
What other resources are available to your Laboratory
1200 Response Network (LRN) and your public health lab to
assist with specimen processing and reporting?
How is information shared and coordinated within the
1200
OA, region and state entities?
How will the local public health department manage the
1200
asymptomatic or “worried well”?

86
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
LOCAL PUBLIC HEALTH DEPARTMENT

Real Scenario Message Receiving Information Local Public Health Department Message/Event Anticipated
Time Time Event # Officer Source Response
Statistics for the Operational Area (county):
o Number of patients admitted with possible
pneumonic plague:
o Number of patients treated and triaged to home with
symptomatic care, including mild symptoms, the
1230 asymptomatic/unexposed (e.g., worried well) and
pre-symptomatic patients:
o Number of patients waiting to be seen:
o Estimated number of persons requiring mass
prophylaxis:
Number of deceased:
How will you develop risk communication messages to
1230 address the information and recommendation needs of
healthcare providers?
How rapidly (and realistically) can these messages be
1230
developed, approved, and disseminated?
How will you collaborate with the Joint Information
1230
Center to ensure consistent messages?
How will you disseminate the risk communication
message and recommendations?
o To healthcare providers?
o Hospitals
o Clinics and MD Offices
o EMS
1230
o Long term care facilities
o Others
o To the public?
o To the media?
o To government officials
o Other responders?

87
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
LOCAL PUBLIC HEALTH DEPARTMENT

Real Scenario Message Receiving Information Local Public Health Department Message/Event Anticipated
Time Time Event # Officer Source Response
1330 What is the current situation status of the facility/service?
1330 What are the critical issues and resources?
What are the operational objectives for the operational
1330
period of 3:30 pm until 11:00 pm?
1330 What staffing is needed?
How are limited resources being allocated and
1330 prioritized? Who makes these decisions and how are
they conveyed to the staff and community?
1330 How will the facility be staffed?
How will the Department Operations Center be staffed?
1330
Can any positions be demobilized?
What community “volunteer” resources can be utilized by
1330 your facility to assist with the surge of patients which are
expected to continue for an extended period of time?
How will you address the behavioral health/psychosocial
needs of the staff, volunteers, physicians, and patients,
1330
including Critical Incident Stress Management/Debriefing
(CISM/D)?
How will your facility or service ensure business
continuity, maintenance of those essential or critical
1330
services, and continue to provide community care
services?
How will your facility deal with the substantial increase in
1330 sanitation needs, demand for food/drink, and patient
holding areas due to the patient surge?

88
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
LOCAL PUBLIC HEALTH DEPARTMENT

Real Scenario Message Receiving Information Local Public Health Department Message/Event Anticipated
Time Time Event # Officer Source Response
DEVELOP AN INCIDENT ACTION PLAN
o What other organizations or responders could/should
also receive the Incident Action Plan (IAP) to
facilitate communication and response among
1330 partners?
o How will you communicate the IAP to the appropriate
agencies?
o From which agencies would it be helpful to receive
their IAPs?
EXECUTE A SHIFT CHANGE
o Conduct an incident briefing and report of current
situation status
o Announce a formal transfer of command
1500 o Report the Incident Action Plan for the next
operational period
o Replace off going personnel with oncoming
personnel (or simulate a change of positions in the
command centers)
Local public health has established mass prophylaxis
clinics in the following locations:
1.
2.
1600
3.
4.
5.
6.

89
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
LOCAL PUBLIC HEALTH DEPARTMENT

Real Scenario Message Receiving Information Local Public Health Department Message/Event Anticipated
Time Time Event # Officer Source Response
CONDUCT A PRESS CONFERENCE
o What community or governmental agencies should
participate in the press conferences (e.g., hospitals,
EMS providers, clinics, healthcare facility officials,
local government, and physicians)?
o Who is the most appropriate person(s) to represent
the healthcare facility at the press conference(s) and
who makes this decision?
o How often should the press conferences be
1600 scheduled?
o Where should the press conferences be convened
within the community?
o Who is the “lead” agency for the press conferences?
o What steps have been taken to ensure a consistent
message among the healthcare community and all
levels of government agencies/officials? Who makes
the final decision about information to be conveyed
when there is conflict among the responding
agencies?
LONG TERM PLANNING/RECOVERY
Activate current processes and procedures to procure
essential resources needed currently and the next 24
1630
hours. If no processes or procedures exist, what
possible actions and plans can be taken to procure the
resources?
Can vendors be protected from exposure or provided
1630
prophylaxis to ensure delivery of needed resources?

90
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
LOCAL PUBLIC HEALTH DEPARTMENT

Real Scenario Message Receiving Information Local Public Health Department Message/Event Anticipated
Time Time Event # Officer Source Response
What resources and mechanisms are available to
procure the needed supplies and equipment and who or
what agency is contacted to provide those resources?
o Intra-hospital resources
1630
o Inter-hospital resources
o Community resources, including city and county
o County resources, including the MHOAC in the EOC
o Others
What are the proper channels of communication and
1630 who or what agency is contacted to obtain those
resources?
What non-medical resources may be needed in the
1630 event (e.g., security, law enforcement, sanitation, water,
transportation)?
How will you maintain evidence/chain of custody for the
1630 dead bodies resulting from the bioterrorism/mass
casualty event?
What non-medical resources may be needed in the
1630 event? (e.g., security, law enforcement, sanitation,
water, transportation)
1645 Report clinic status to the MHOAC/OA EOC.

91
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
MASTER SEQUENCE OF EVENTS LIST
LOCAL PUBLIC HEALTH DEPARTMENT

Real Scenario Message Receiving Information Local Public Health Department Message/Event Anticipated
Time Time Event # Officer Source Response
THE EXERCISE ENDS
Conduct an exercise debriefing with HCC and
departmental staff immediately upon termination of the
exercise.

Post exercise activities may include:

o Formal debriefing and incident review session with
1700 key personnel and the Emergency Preparedness
Committee.
o Development of an After-Action Report (AAR).
o Development of a Corrective Action Plan (CAP),
including timelines and deadlines for improvements.
o Dissemination of the AAR and CAP to key internal
and external stakeholders.
o Planning for the next exercise.

92
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

Conducting the
Exercise

93
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

Exercise Planning Assumptions

During planning of the 2007 Statewide Medical and Health Disaster Exercise, the following
planning assumptions were used to develop the scenario and the guidebook:

‰ The target audience for this exercise is acute care hospitals, community clinics, public
and private EMS providers, and local public health departments. The Guidebook is
geared to and provides scenario prompts for those groups. Other healthcare providers
and local emergency management are encouraged to participate, scripting scenario
prompts to meet the organizations exercise objectives and participate in a community
exercise.

‰ The exercise scenario focuses on the following elements of response to and recovery
from a patient surge event:
o Activation of surge plans including alternate care sites and augmentation of
personnel
o Resource management (e.g., equipment, supplies, pharmaceuticals)
o Activation of MOUs and other support agreements
o Activation of security plans and use of Internal and external security forces
o Management of public information, including conducting a media briefing/press
conference
o Exercise Incident action planning, transfer of command in the Hospital Command
Center, and shift change processes

‰ Due to the compressed timeframe of the exercise, there are multiple activities, actions
and decision-making events scripted early in the scenario/events. In an actual event,
the events in the scenario would occur over days, and not in 12 hours. This artificiality is
built into the scenario to stimulate play and exercise surge plans.

‰ Regional and State governmental agencies (e.g., Regional Emergency Operations

centers, Joint Emergency Operations Center, State Operations Center) are not
participating in the exercise this year. Therefore, operational areas and local
participants may plan for the simulation of these agencies to enhance the exercise play.

‰ Auxiliary Communications Systems (ACS) are not activated during this scenario.
However, participants may activate internal and/or external systems to exercise and test
ACS during the exercise.

‰ The Intelligence messages included in the exercise are intended to test communications
of intelligence messages to healthcare providers. The California intelligence
community/agencies are not participating in the exercise, so the communication of
intelligence is being simulated. Pre-exercise intelligence messages will be distributed to
healthcare providers through CDPH, EMSA, and CHA to simulate the system. Two
different messages will be distributed on Monday, October 22nd and on Wednesday,
October 24th.

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Pre-Exercise Activities
Preparing the Materials
Obtain the 2007 Statewide Medical & Health Disaster Exercise Guidebook for the October 25,
2007 exercise from the Emergency Medical Services Authority at
http://www.emsa.ca.gov/dms2/dms_exercises.asp.

Notifying the Operational Area (OA) Exercise Coordinator of Intent to Participate

Exercise participants should report their intent to participate in the 2007 Statewide Medical and
Health Disaster Exercise no later than September 28, 2007, using the Intent to Participate form
on page 101. The participant will fax the Intent form to the OA Exercise Contact at the number
listed on page 146.

The OA Exercise Contact is encouraged to communicate with the RDMHS about the number
and level of exercise participants in the OA. Note, this year, there is no OA Exercise Contact
report required to be completed and submitted to the RDMHS.

Exercise Planning in the OA

The OA Exercise Coordinator may convene meetings with OA exercise participants to plan and
coordinate the exercise. Exercise participants should contact their OA Exercise Contact (see page
146) to discuss OA planning and coordination.

The exercise participant should prepare an exercise contact list for their organization for the OA
Exercise Contact. Examples of numbers to provide include the Hospital Command Center
(HCC), the facility exercise coordinator, the Incident Commander, and other key contacts.

‰ Invite other participating agencies, departments or organizations to briefings or training

for the exercise.
‰ Contact and update other agencies, departments or organizations about any last-minute
changes in participation or communications.
‰ Assist the participants in finding community volunteers to participate in the exercise to
increase realism in the play.
‰ Complete HICS Form 258: Hospital Resource Directory to identify critical resources.

Other Recommended Contacts and Participants in the Operational Area

Expanding the exercise in your OA is strongly recommended and encouraged. The following
entities can be considered for involvement in the exercise, if possible:
9 Clinics/clinic consortiums
9 Ambulance providers
9 Skilled nursing/long-term care facilities
9 MMRS (if applicable in the city/OA)
9 Local law enforcement
9 Local fire departments
9 Local schools and/or school officials (even if only in a tabletop)
9 Medical Examiner/Coroner
9 911 Dispatch Center
9 Local Terrorism Early Warning Groups
9 Environmental Health
9 Public Utilities
9 OA Office of Emergency Services
9 American Red Cross
9 Others as identified by the scenario or the unique OA entities
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Coordination with the Media

Collaborate with the organizations Public Affairs Department and the other participant Public
Information Officers (PIO) to determine how the “real-life” (not the exercise simulated) media will
be addressed during the planning process (media or press releases), during the exercise (press
briefings and conferences, written risk communication messages), and post exercise
(communicating the success of your community-wide exercise). Prepare media releases in
advance and sound bites can even be pre-recorded. For examples of a media release, see
page 104.

Scheduling Personnel, Space, and Equipment

It is recommended that facility and organization staff assigned to the exercise are notified well in
advance to coordinate their schedules and plan for participation. For critical exercise positions
or assignments, consider scheduling back-up staff that are also briefed and trained prior to the
exercise.
‰ Announce the exercise date on local agencies/departments calendars, in-house
publications or computer schedules so all involved personnel save the date when they
are scheduling other activities.
‰ Identify and reserve the exercise location/space before the exercise.
‰ Assess the exercise area to make sure construction or other changes do not hinder the
layout for performance of the exercise (e.g., removal of the phone lines from the room,
or removal of chairs and tables.)
‰ Develop a checklist of equipment you will need to support the exercise.
‰ Check all equipment for proper functioning and operation before the exercise.

Developing Local Scenarios

The scenario in the 2007 Statewide Medical & Health Disaster Exercise Guidebook details a
sequence of events to be used by participants. This sequence provides the overall anticipated
schedule of activities that all participants will incorporate into the community exercise. Local
agencies and departments may alter the scenario to meet their exercise objectives. The scenario
is also developed to allow customization at the hospital and local level in regards to overall patient
numbers and existing policies.

Exercise Day Activities

Pre-Exercise Survey of Resources

Changes often occur at the last minute and can interfere with a successful exercise. Organize a
team of “checkers” who do nothing more than check facility readiness, materials, storage lockers,
phones, fax machines and other communications systems the evening before and the morning of
the exercise.

Briefing of Participants
Provide participating personnel with job action sheets, background information, organizational
charts, pertinent policies and procedures, and role expectations before the exercise begins to
increase participant comfort level and exercise success. At the minimum, the facility should be
aware of the exercise in progress.

“This Is An Exercise!”
During the briefings, and throughout the exercise, it is very important to emphasize “this is an
exercise” to all participants, agencies, and departments. Written materials and scripts should
denote “Exercise only”, or “This is an Exercise”. Oral communications should be proceeded and
end with “This is an exercise”.

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Facility Signage
It is important to notify staff, patients, and visitors that an exercise in being conducted. Consider
posting large signs at facility entrances and in key locations around the facility stating “Disaster
Exercise in Progress” or similar language, to inform people of the event. Staff on-duty at the
information desks in the entrance to the facility should also be given exercise information to
inform visitors and others entering the facility about the exercise.

Exercise Safety
If exercise play within your facility includes volunteers or staff playing the role of casualties, you
must activate an exercise safety officer to ensure safe conduct of the exercise. This should include
a designated “code word” for the exercise volunteers to use in case of an unsafe or uncomfortable
situation. The Exercise Safety Officer will notify the Lead Exercise Controller to temporarily
suspend exercise play until the situation is resolved. In addition, volunteers should have proper
identification and clear instructions on their role and scope of participation.

HICS Forms
If your facility has been trained in the use of the (new) HICS forms for incident action planning,
stock these in your Hospital Command Center for use in the exercise. Forms are available on the
EMSA web site at www.emsa.ca.gov/hics/hics.asp. These forms should be used in developing,
documenting and communicating your Incident Action Plan for each operational period.

Terminating the Exercise for an Actual Emergency

Should there be a need to totally stop the exercise due to a real-time situation or event, the
organization’s exercise controller will give a “Terminate the Exercise” order and all exercise
should be immediately terminated until the situation can be determined.

There may be situations where a real-time event, participant injury, or other situation may occur
where the exercise should be stopped only in that area of play, but not necessarily the entire
exercise. The exercise controller will announce a “Pause the Exercise in [name of area or
department]” to pause the play until the situation can be addressed.

Reporting Situation/Status Information to the OA

Each participating agency will compile situation and status information utilizing their own
operational area forms and submit reports according to OA policies.

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Conducting the 2007 Exercise

Tips for Hospitals
This year, the Medical and Health Disaster Exercise scenario is providing participants with an
opportunity to expand their facility-wide exercise. Many times, the drills and tabletops
conducted have focused on the emergency department (ED) and emergency services and have
not impacted all units and/or departments in the facility. This year, the scenario focuses on the
entire healthcare facility and its ability to manage a large influx of patients and address the
allocation of scarce resources including staffing, beds, equipment, supplies, services (e.g.,
laboratory) and pharmaceuticals.

There are different types of exercises you can conduct, including tabletop, functional, and full
scale (see glossary for definition of exercises, page 133). Each of these exercises can test your
response and management of a patient surge event.

The following are some recommendations to achieve hospital-wide participation in the exercise:

‰ Activate the Emergency Operations Plan (EOP), the Hospital Command Center (HCC) and
the Hospital Incident Command System (HICS) to manage the event and address the policy
issues as described in the scenario. Incorporate into the activation personnel who may not
have previously played a role in the HCC, such as infectious disease practitioners,
epidemiologists, Infection Control staff, occupational health staff and others.
‰ Utilize the HICS Forms for development of your hospital incident action plan.
‰ Activate high census plans in all departments and move “live” volunteer patients, or paper
patients as appropriate to vacate beds and accept new patients.
‰ Mobilize the infectious disease practitioners/infection control department to assist in
determining facility priorities, patient care management, staff protection and reporting to
local public health.
‰ Select a department or unit within the facility to cohort infectious patients. (See glossary
page 133 for definition of cohorting.) Task engineering to devise a plan to isolate the
Heating, Ventilation and Air Conditioning (HVAC) system for the designated area and task
nursing to plan for setting up supplies and equipment set up and staffing the unit.
‰ Test the callback (staff notification) systems and lists, update lists and procedures as
appropriate.
‰ Activate and practice “just-in-time” fit testing of N-95 masks and medical screening of
employees to ensure employee protection in caring for infectious patients. The “fit testing”
should include clinical and non-clinical support staff (e.g., housekeeping, dietary,
engineering, security).
‰ Inventory all linen, nutritional supplies (food) and environmental services equipment and
supplies to determine if additional quantities will be needed for the large patient influx and
high patient census.
‰ Activate internal and external security plans and institute traffic control measures, visitor
access and set up perimeter barricades, etc.
‰ Prepare a plan to “lock down” the facility defining under what authority, when and how a
“lock down” would occur and when the “lock down” would be discontinued. Review the
ability to maintain ongoing ED services in the event of a lock-down and the ability to receive
ambulance traffic and walk-in patients.

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‰ Implement hospital lab procedures to manage specimens from infectious patients in large
numbers, including laboratory staffing, specimen prioritization and processing, and
communication with local public health/Laboratory Response Network (LRN). Mock up the
proper packaging and secure shipping of specimens to the local public health laboratory
through the Laboratory Response Network.
‰ Arrange for the influx of patients using “live” volunteer patients (or paper patients) presenting
at the ED as described in the scenario.
‰ Stage a convergence of volunteers into the facility offering clinical and non-clinical
assistance with live persons (or paper volunteers). How will the facility deal with and
manage these well-meaning volunteers presenting? How will the licensing and credentialing
issues be dealt with?
‰ Assess quantities of pharmaceuticals (antibiotics) available in the facility to treat pneumonic
plague.
‰ Develop or activate existing plans to provide prophylaxis to hospital staff. Determine priority
of hospital staff treatment based on available antibiotics on site, distribution site(s) within the
hospital, and tracking and follow-up for staff receiving prophylaxis.
‰ Institute procedures in business office and patient registration to manage an overwhelming
number of patients and implement Hospital Information System/ Information Technology
emergency policies and procedures to accommodate the business needs of the facility.
‰ Activate your media relations or public information officer to respond to multiple media calls
for information and/or convergence of media into your facility.
‰ Assess your capability to track patients throughout the hospital, including the hospital-based
alternate care sites and to other patient care destinations, in accordance with applicable law
and regulations.
‰ Activate your business continuity plan to return to normal or near-normal operations.
‰ Activate your hospital or community joint information system for risk communication and
messaging.

These are only a few of the ideas to conduct a successful exercise to engage and involve
multiple units/departments in a hospital. Use your imagination and be creative in your planning
for the 2007 Statewide Medical and Health Disaster Exercise!

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Intent to Participate
&
Reporting Participation

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INTENT TO PARTICIPATE
Please complete this form to indicate your intent to participate in the exercise.

FAX THIS FORM TO THE OPERATIONAL AREA EXERCISE CONTACT (LISTED IN PAGE 146)
BY FRIDAY, SEPTEMBER 28, 2007.

Type of Provider: Hospital Community Clinic Ambulance

Public Health Department Other:

Name of Facility or Provider:

Address:

City Zip

County:

Exercise Coordinator or Contact:

Telephone #: Fax #:

E-mail:

There are many levels of participation in the October 25, 2007 exercise, including:

Full-scale exercise
Functional exercise (See Glossary for exercise definitions)
Table top exercise
Communications exercise
Other (specify):

Time and Number of Hours of exercise play: Time: # Hours:

Please complete this form for each healthcare facility, ambulance provider or entity participating
in the exercise. If you are a multiple facility or multi-campus facility,
complete one “Intent to Participate” Form for each individual facility participating.

The form may be duplicated for this purpose.

FAX THIS FORM TO THE OPERATIONAL AREA EXERCISE CONTACT (LISTED IN PAGE 146) BY
FRIDAY, SEPTEMBER 28, 2007.

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Sample
Media Release

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Your logo
Sample
Or
Public Information Officer
Letterhead Media Advisory
Here
Statewide Medical and Health Disaster Exercise
October 25, 2007

Date: October XX, 2007 Contact: Jane Doe

(XXX) XXX-XXXX

What: California is conducting its ninth annual Statewide Medical & Health Disaster
Exercise. Hospitals, ambulance providers, public health departments and local
governmental agencies across the state will voluntarily participate in the
exercise. The scenario for the exercise is a biological event with Yersinia pestis
(or plague). The objective is to exercise the response of healthcare providers and
governmental agencies to manage the influx of large numbers of ill and infectious
patients.

When: Thursday, October 25, 2007 from 5:00 am to 5:00 pm

Where: In hospitals, community clinics, public health departments, Emergency Medical

Services (EMS)/ambulance services, and local governmental agencies
throughout the State of California.

Who: Exercise planners and supporters of this exercise include the California
Department of Public Health, Emergency Medical Services Authority, the
California Hospital Association, hospitals, community clinics, local EMS
agencies, and local public health departments.

Background: Participating in this exercise will help California healthcare organizations and its
communities to be better prepared to respond to an actual disaster, should one
occur. Hospital participation in this exercise also qualifies as a formal disaster
drill with an influx of patients and involvement in community-wide planning and
exercising as defined by The Joint Commission. Participation in this exercise
also meets some exercise requirements as set forth in Federal and State grants.

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Evaluating
The Exercise

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Exercise Evaluation

Exercise Evaluation Tools

Exercises must be evaluated to measure performance and identify corrective actions.
Exercises are critiqued to identify deficiencies and opportunities for improvement based upon
monitoring activities and observations during the exercise (Joint Commission E.C. 4.20, B15.)

Using and/or adapting existing tools can facilitate exercise evaluation. Exercise evaluation can
assist organizations to identify:
• Needed improvements in the Emergency Management Program, Emergency
Operations Plan, procedures, or guidelines
• Enhanced collaboration and cooperative planning with community agencies
(community-wide planning)
• Needed improvements in the emergency management system, including the incident
command and control
• Training and staffing deficiencies
• Whether the exercise has achieved its objectives
• Needed equipment, supplies or services
• Needs for continued exercises on the plan or its functions

An evaluation tool to consider is the Homeland Security Exercise and Evaluation’s Exercise
Evaluation Guides. These guides are used nationally to evaluate exercises and several of the
guides pertain to healthcare. Information about EEGs can be found at
https://hseep.dhs.gov/EEGsAbout.htm, and a library of available EEGs at
https://hseep.dhs.gov/EEGSListings.htm.

Conducting a Player Hotwash

(This information and the following form is from the Homeland Security Exercise and Evaluation Program, Volume III:
Exercise Evaluation and Improvement Planning. The information can be found at https://hseep.dhs.gov/.)

Immediately after an exercise, evaluators (or team of evaluators and controllers) should debrief
the players and controllers in his/her observed discipline, either separately or as a large group.
This facilitated discussion, referred to as a hotwash, allows players to engage in a self-
assessment of their exercise play and provides a general assessment of how the entity
performed in the exercise. The hotwash also provides evaluators with the opportunity to clarify
points or collect any missing information from players before they leave the exercise venue. The
hotwash is conducted as soon as possible after the exercise, usually the same day. In exercises
with several venues, separate hotwashes may take place at each location. A hotwash is led by
an experienced facilitator who can ensure that the discussion remains brief and constructive,
and who can focus conversation on strengths and areas for improvement.

During the hotwash, evaluators may distribute Participant Feedback Forms (see example on
following pages to obtain information on perceptions of the exercise, how well each player
thought his/her unit performed, and how well the unit integrated performance with other
agencies and other exercise components. The questions on the Participant Feedback Form
can also be used to conduct a verbal hotwash, rather than written.

The information can provide insight into why events happened the way they did or why some
expected actions did not take place. Participant Feedback Forms are collected at the end of the
hotwash and reviewed by the evaluation team to augment existing information. Participant

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Feedback Forms also serve to solicit general feedback on exercise quality, which can be
provided to the exercise planning team to help implement improvements in future exercises. A
summary of Participant Feedback Forms can be included as an optional appendix within an
after-action report/corrective action plan.

Tips for Conducting a Successful Hotwash or Debriefing

• The hotwash should be conducted by an exercise controller or exercise planner who is well
informed about the exercise scenario and objectives.
• A successful hotwash facilitator should stay within the time allotted for the debriefing,
encourage participation from all members of the group, and be proficient in conflict
resolution. Be prepared for negative comments about the exercise and the overall
emergency management program. Exercises can be stressful for participants and they may
share their concerns and frustrations. Be patient, non-judgmental, and listen with an open
mind.
• Appoint a scribe: the hotwash facilitator should focus on that role and not on note taking.
• Keep a sign in sheet with name, department, area of assignment for the exercise and the
role played (e.g., participant, controller, evaluator, victim).
• Set the tone for the hotwash/debriefing: make it positive and non-threatening. Many
hotwashes focus on identifying “what worked, what did not work”. Begin by focusing on the
positive: “what worked”. Ask participants to identify those areas they felt worked well,
looking for innovative approaches in response and problem solving
• When participants get off track during the hotwash, refer to the objectives and the purpose
of the debriefing. Acknowledge participants concerns, and refer them to the evaluation
sheets as a method for voicing and documenting issues.
• Use humor to keep on time and on track.
• Keep on an eye on the audience: look for those individuals who are having difficulty finding
an opportunity to speak.
• Use the objectives to move the discussion: refer to a specific objective and ask for input.
• When concluding the hotwash, identify the next steps to be taken
o All verbal and written comments will be reviewed
o Action items will be identified and an action plan developed
o Educational issues will be identified and addressed

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PARTICIPANT FEEDBACK FORM

Exercise Name: [Exercise Name] Exercise Date: [Date]

Participant Name: ___________________________ Title: ___________________________

Agency: __________________________Role: __Player __Controller __Evaluator __Observer

Part I – Recommendations and Action Steps

1. Based on the exercise today and the tasks identified, list the top 3 issues
and/or areas that need improvement.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

2. Identify the action steps that should be taken to address the issues
identified above. For each action step, indicate if it is a high, medium, or
low priority.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

3. Describe the action steps that should be taken in your area of responsibility.
Who should be assigned responsibility for each action item?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

4. List the equipment, training or plans/procedures that should be reviewed,

revised, or developed. Indicate the priority level for each.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
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Part II – Exercise Design and Conduct

1. What is your assessment of the exercise design and conduct?

Please rate, on a scale of 1 to 5, your overall assessment of the exercise relative to the statements provided
below, with 1 indicating strong disagreement with the statement and 5 indicating strong agreement.

Rating of Satisfaction with

Exercise
Strongly Strongly
Assessment Factor Disagree Agree

a. The exercise was well structured and organized. 1 2 3 4 5

b. The exercise scenario was plausible and realistic. 1 2 3 4 5

c. The documentation used during the exercise was a valuable

1 2 3 4 5
tool throughout the exercise.

d. Participation in the exercise was appropriate for someone in my

1 2 3 4 5
position.

e. The participants included the right people in terms of level and

1 2 3 4 5
mix of disciplines.

2. What changes would you make to improve this exercise?

Please provide any recommendations on how this exercise or future exercises could be improved or
enhanced.

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________________

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Master Answer Sheets

&
Evaluation Questions

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ACUTE CARE /HOSPITAL FACILITY

MASTER ANSWER SHEET – PAGE 1 OF 2
Complete this Master Answer Sheet for responses to the Acute Care/Hospital Facility
Exercise Evaluation Questions and mail ONLY THESE TWO PAGES to the address below.
NOTE: THESE MAY BE COMPLETED ON THE COMPUTER AND PRINTED

Hospital/Healthcare Facility Name:

Address:

City: Zip:

Operational Area: (See map on page 152)

Disaster Coordinator/Evaluator Name:

Telephone #: Fax #:

E-mail:

CHECK/ENTER THE APPROPRIATE ANSWERS

Question 1: A B C D E F G

Question 2: A B C D

Question 3: A B C

Question 4: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 5: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 6: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 7: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 8: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 9: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 10: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 11: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 12: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 13: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 14: Fully met Partially met Did not meet Not applicable/Not Exercised

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ACUTE CARE /HOSPITAL FACILITY
MASTER ANSWER SHEET – PAGE 2 OF 2

NAME OF FACILITY:

Question 15: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 16: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 17: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 18: A B - What other objective?

Question 19: A B C

Question 20: A B C

Question 21: A B C

Question 22: A B C

Question 23: A B C

Question 24:
Area hospitals Community clinics Local public health Local OES
EMS Providers Law Enforcement Long-term Care Facilities
Coroner/medical examiner Terrorism Early Warning groups
911 dispatch centers Local school districts
Non-governmental agencies (e.g., American Red Cross, religious organizations)
Other: (specify)

Question 25: A B C

Question 26: A B C

Question 27: A B C D E

Question 28: 0500–0700 0700-0900 0900-1100 1100-1300

1300-1500 1500-1700 Other:

Question 29: A. No, the messages were injected by the hospital.

B. Yes. The information originated from:

Question 30: A B C

Mail by NOVEMBER 9, 2007 to:

Emergency Medical Services Authority
1930 9th Street
Sacramento, CA 95814
Attn: Statewide Exercise Evaluation

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HOSPITAL AND HEALTHCARE SYSTEM EXERCISE EVALUATION QUESTIONS

Please use the attached Master Answer Sheet when recording your responses. Be sure to
complete every question before submitting the Master Answer Sheet (page 111). Certificates
for Participation will be provided only upon receipt of the 2007 Exercise Participation Evaluation
Master Answer Sheet.

1. Circle the single best answer which describes your facility.

A. Acute care hospital with a basic or comprehensive emergency department
B. Acute care hospital with a stand-by emergency department
C. Acute care hospital with no emergency department
D. Psychiatric hospital
E. Specialty care hospital
F. Long-term care facility
G. Other

2. Please indicate the level of participation of your facility during the exercise. (See
Glossary on Page 133 for definitions of exercises.)
A. Full Scale Exercise
B. Functional Exercise
C. Tabletop Exercise
D. Communications Exercise

3. Does your hospital utilize the Hospital Incident Command System (HICS) or the Hospital
Emergency Incident Command System (HEICS)?
A. Yes
B. No
C. For information on HICS: visit www.emsa.ca.gov/hics/hics.asp

4. Objective I: Pre-Exercise Event: Did you plan for and integrate your exercise with
community response partners? (Detail partners in Question 23)

Fully met Partially met Did not meet Not applicable/Not Exercised

5. Objective II: Did you activate the Emergency Operations Plan and the incident
command system (e.g., HICS)?

Fully met Partially met Did not meet Not applicable/Not Exercised

6. Objective III: Did you exercise the hospital’s surge plans to expand capacity and
manage a large influx of patients?

Fully met Partially met Did not meet Not applicable/Not Exercised

7. Objective IV: Did you activate hospital-based alternate care sites?

Fully met Partially met Did not meet Not applicable/Not Exercised

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HOSPITAL AND HEALTHCARE SYSTEM EXERCISE EVALUATION QUESTIONS

8. Objective V: Did you track patients throughout the hospital campus including alternate
care sites?

Fully met Partially met Did not meet Not applicable/Not Exercised

9. Objective VI: Did you communicate response efforts to staff, patients, their families and
external agencies using appropriate forms and status reports?

Fully met Partially met Did not meet Not applicable/Not Exercised

10. Objective VII: Did you exercise the provision of prophylaxis to hospital staff, physicians,
volunteers, current patients and others as appropriate?

Fully met Partially met Did not meet Not applicable/Not Exercised

11. Objective VIII: Did you exercise plans, policies and procedures to augment personnel
resources during a prolonged surge event, including the use of volunteers and
community resources?

Fully met Partially met Did not meet Not applicable/Not Exercised

12. Objective IX: Did you exercise resource management, including the allocation of scarce
resources (e.g., ventilators, negative-pressure isolation capacity, personal protective
equipment, critical care beds, pharmaceuticals)?

Fully met Partially met Did not meet Not applicable/Not Exercised

13. Objective IX: Did you communicate hospital needs to outside sources (e.g., vendors) in
order to ensure the supply chain?

Fully met Partially met Did not meet Not applicable/Not Exercised

14. Objective X: Did you exercise plans to secure the hospital facility and grounds to protect
staff, volunteers, physicians, patients, visitors, and assets using internal and external
resources?

Fully met Partially met Did not meet Not applicable/Not Exercised

15. Objective XI: Did you exercise hospital laboratory policies and procedures to
communicate to the local public health laboratory and/or local Laboratory Response
Network (LRN) to determine appropriate specimen/sample preparation and shipment to
the LRN laboratory?

Fully met Partially met Did not meet Not applicable/Not Exercised

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HOSPITAL AND HEALTHCARE SYSTEM EXERCISE EVALUATION QUESTIONS

16. Objective XII: Did you exercise information management plans and develop public
information messages consistent with local authorities (Operational Area Joint
Information Center) and other healthcare providers for internal (current patients, staff,
volunteers, physicians, visitors) and external dissemination (media, others)?

Fully met Partially met Did not meet Not applicable/Not Exercised

17. Objective XIII: Did you exercise the activation of MOUs or other support agreements
between the hospital and community partners, private entities, vendors and/or others?

Fully met Partially met Did not meet Not applicable/Not Exercised

18. Did you develop and implement another objective for the exercise?

A. No, the exercise objectives stated in the guidebook were used.

B. Yes. What objective?

19. Did you extract various “modules” from the 12-hour exercise scenario to create an
exercise for your organization to meet your exercise objectives?
A. Yes, we used multiple modules to create our own exercise.
B. No, we used the scenario as written.
C. Don’t know.

20. Did you conduct a shift change during the exercise?

A. Yes
B. No
C. Don’t know

21. Did you conduct and document incident action planning in the Hospital Command
Center (HCC)?
A. Yes
B. No
C. Don’t know

22. Did you conduct a media briefing/press conference during the exercise?
A. Yes
B. No
C. Don’t know

23. Did you exercise your mass fatality plans?

A. Yes
B. No
C. Don’t know

114
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

HOSPITAL AND HEALTHCARE SYSTEM EXERCISE EVALUATION QUESTIONS

24. What other community response partners did you exercise with? (Check all that apply)

Area hospitals Community clinics Local public health Local OES

EMS Providers Law Enforcement Long-term Care Facilities
Coroner/medical examiner Terrorism Early Warning groups
911 dispatch centers Local school districts
Non-governmental agencies (e.g., American Red Cross, religious organizations)
Other: (specify)

25. Was the guidebook useful in planning your exercise?

A. Yes
B. No
C. Don’t know

26. Was the scenario realistic and allow for testing of the surge plan?
A. Yes
B. No
C. Don’t know

27. How many total hours did you conduct an exercise in your facility?
A. 1 - 4 hours
B. 5 - 6 hours
C. 7 - 8 hours
D. 8 - 10 hours
E. 11 - 12 hours

28. What time did you exercise? (Check all that apply)
0500–0700 0700-0900 0900-1100 1100-1300

1300-1500 1500-1700 Other:

29. Did you receive the exercise scenario intelligence messages disseminated on 10-22 and
10-24-07?

A. No, the messages were injected by the hospital.

B. Yes. The information originated from:

30. The Statewide Medical and Health Disaster Exercise is conducted annually in the fall.
There is a recommendation to move the exercise to Spring (April or May) instead of the
fall each year. This would allow medical and health providers to exercise collaboratively,
but to also avoid conflicts with Golden Guardian and other annual fall events. Would you
support this change and exercise in Spring?

A. Yes, I would support a Spring exercise and participate

B. No, I would not support a Spring exercise, leave the exercise in the fall
C. Other (describe on back of Master Answer Sheet)

115
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

HOSPITAL AND HEALTHCARE SYSTEM EXERCISE EVALUATION QUESTIONS

Additional Comments and Recommendations?

Please write additional comments on the back of the Master Answer Sheet and attach additional
pages as needed. We very much appreciate your feedback!

Complete the Master Answer Sheet on page 111 and mail to:

Emergency Medical Services Authority

1930 9th Street
Sacramento, CA 95814
Attn: Statewide Exercise Evaluation

116
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

COMMUNITY CLINIC
MASTER ANSWER SHEET
PAGE 1 OF 2

Complete this Master Answer Sheet for responses to Community Clinic Exercise
Evaluation Questions and MAIL ONLY THESE TWO PAGES to the address below.
NOTE: THESE MAY BE COMPLETED ON THE COMPUTER AND PRINTED

Community Clinic Name:

Address:

City: Zip:

Operational Area: (See map on page 152)

Disaster Coordinator/Evaluator Name:

Telephone #: Fax #:

E-mail:

CHECK THE APPROPRIATE ANSWER

Question 1: A B C D

Question 2: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 3: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 4: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 5: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 6: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 7: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 8: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 9: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 10: A B C

Question 11: A B C

Question 12: A B C

Question 13: A B C

117
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
COMMUNITY CLINIC
MASTER ANSWER SHEET
PAGE 2 OF 2

NAME OF FACILITY:

Question 14:
Area hospitals Community clinics Local public health Local OES
EMS Providers Law Enforcement Long-term Care Facilities
Coroner/medical examiner Terrorism Early Warning groups
911 dispatch centers Local school districts
Non-governmental agencies (e.g., American Red Cross, religious organizations)
Other: (specify)

Question 15: A B C

Question 16: A B C

Question 17: A B C D E

Question 18: 0500–0700 0700-0900 0900-1100 1100-1300

1300-1500 1500-1700 Other:

Question 19: A. No, the messages were injected by the hospital.

B. Yes. The information originated from:

Question 20: A B C

Mail by NOVEMBER 9, 2007 to:

Emergency Medical Services Authority
1930 9th Street
Sacramento, CA 95814
Attn: Statewide Exercise Evaluation

118
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

COMMUNITY CLINIC EXERCISE EVALUATION QUESTIONS

Please use the attached Master Answer Sheet when recording your responses. Be sure to
complete every question before submitting the Master Answer Sheet (page 118). Certificates
for Participation will be provided only upon receipt of the 2007 Exercise Participation Evaluation
Master Answer Sheet.

1. Please indicate the level of participation of your clinic during the exercise. (See
Glossary on Page 133 for definitions of exercises.)
A. Full Scale Exercise
B. Functional Exercise
C. Tabletop Exercise
D. Communications Exercise

2. Objective I: Did you activate the clinic’s Emergency Operations Plan and the incident
command system?

Fully met Partially met Did not meet Not applicable/Not Exercised

3. Objective II: Did you communicate response efforts to staff, patients, their families and
external agencies using appropriate forms and status reports?

Fully met Partially met Did not meet Not applicable/Not Exercised

4. Objective III: Did you exercise the plan and capability to provide prophylaxis for clinic
staff?

Fully met Partially met Did not meet Not applicable/Not Exercised

5. Objective IV: Did you exercise your plans for securing the clinic facility and grounds to
protect staff, volunteers, physicians, patients, visitors and assets?

Fully met Partially met Did not meet Not applicable/Not Exercised

6. Objective V: Did you assess the ability to or exercise the expansion of capacity using
non-traditional patient care areas within the facility?

Fully met Partially met Did not meet Not applicable/Not Exercised

7. Objective VI: Did you communicate approximate surge capacity and resource
capabilities to the OA Medical/Health POC?

Fully met Partially met Did not meet Not applicable/Not Exercised

119
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

COMMUNITY CLINIC EXERCISE EVALUATION QUESTIONS

8. Objective VII: Did you assess your capacity to assist other affected clinics in the OA
with resources?

Fully met Partially met Did not meet Not applicable/Not Exercised

9. Objective VIII: Did you coordinate your clinic’s response efforts with local hospitals, city
public works, law enforcement, fire, EMS, and other emergency response teams?

Fully met Partially met Did not meet Not applicable/Not Exercised

10. Did you extract various “modules” from the 12-hour exercise scenario to create an
exercise for your organization to meet your exercise objectives?
A. Yes, we used multiple modules to create our own exercise.
B. No, we used the scenario as written.
C. Don’t know.

11. Did you conduct a shift change during the exercise?

A. Yes
B. No
C. Don’t know

12. Did you conduct and document incident action planning in the command center/EOC?
A. Yes
B. No
C. Don’t know

13. Did you conduct a media briefing/press conference during the exercise?
A. Yes
B. No
C. Don’t know

14. What other community response partners did you exercise with? (Check all that apply)
Area hospitals Community clinics Local public health Local OES
EMS Providers Law Enforcement Long-term Care Facilities
Coroner/medical examiner Terrorism Early Warning groups
911 dispatch centers Local school districts
Non-governmental agencies (e.g., American Red Cross, religious organizations)
Other: (specify)

15. Was the guidebook useful in planning your exercise?

A. Yes
B. No
C. Don’t know

16. Was the scenario realistic and allow for testing of the surge/emergency operations plan?
A. Yes
B. No
C. Don’t know

120
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

COMMUNITY CLINIC EXERCISE EVALUATION QUESTIONS

17. How many total hours did you conduct an exercise in your facility?
A. 1 - 4 hours
B. 5 - 6 hours
C. 7 - 8 hours
D. 8 - 10 hours
E. 11 - 12 hours

18. What time did you exercise (check all that apply)?
0500–0700 0700-0900 0900-1100 1100-1300

1300-1500 1500-1700 Other:

19. Did you receive the exercise scenario intelligence messages disseminated on 10-22 and
10-24-07?
A. No, the messages were injected by the hospital.
B. Yes. The information originated from:

20. The Statewide Medical and Health Disaster Exercise is conducted annually in the fall.
There is a recommendation to move the exercise to Spring (April or May) instead of the
fall each year. This would allow medical and health providers to exercise collaboratively,
but to also avoid conflicts with Golden Guardian and other annual fall events. Would you
support this change and exercise in Spring?

A. Yes, I would support a Spring exercise and participate

B. No, I would not support a Spring exercise, leave the exercise in the fall
C. Other (describe on back of Master Answer Sheet)

Additional Comments and Recommendations?

Please write additional comments on the back of the Master Answer Sheet and attach additional
pages as needed. We very much appreciate your feedback!

Complete the Master Answer Sheet on page 118 and mail to:
Emergency Medical Services Authority
1930 9th Street
Sacramento, CA 95814
Attn: Statewide Exercise Evaluation

121
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

EMS/AMBULANCE PROVIDER
MASTER ANSWER SHEET
PAGE 1 OF 2
Complete this Master Answer Sheet for responses to the Ambulance Provider Exercise
Evaluation Questions and MAIL ONLY THESE TWO PAGES to the address below.
NOTE: THESE MAY BE COMPLETED ON THE COMPUTER AND PRINTED

EMS/Ambulance Provider Name:

Address:

City: Zip:

Operational Area: (See map on page 152)

Disaster Coordinator/Evaluator Name:

Telephone #: Fax #:

E-mail:

CHECK THE APPROPRIATE ANSWER

Question 1: A B C D

Question 2: A B C D E

Question 3: A B C D

Question 4: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 5: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 6: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 7: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 8: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 9: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 10: A B C

Question 11: A B C

Question 12: A B C

Question 13: A B C

122
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
AMBULANCE PROVIDER
MASTER ANSWER SHEET
PAGE 1 OF 2

NAME OF ORGANIZATION:

Question 14:
Area hospitals Community clinics Local public health Local OES
EMS Providers Law Enforcement Long-term Care Facilities
Coroner/medical examiner Terrorism Early Warning groups
911 dispatch centers Local school districts
Non-governmental agencies (e.g., American Red Cross, religious organizations)
Other: (specify)

Question 15: A B C

Question 16: A B C

Question 17: A B C D E

Question 18: 0500–0700 0700-0900 0900-1100 1100-1300

1300-1500 1500-1700 Other:

Question 19: A. No, the messages were injected by the hospital.

B. Yes. The information originated from:

Question 20: A B C

Mail by NOVEMBER 29, 2007 to:

Emergency Medical Services Authority
1930 9th Street
Sacramento, CA 95814
Attn: Statewide Exercise Evaluation

123
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

Ambulance Provider Exercise Evaluation Questions

Please use the Master Answer Sheet (page 123) for Ambulance Providers when recording
your responses. Be sure to complete every question before submitting the Master Answer
Sheet. Certificates for Participation will be provided only upon receipt of the 2007 Exercise
Participation Evaluation Master Answer Sheet.

1. Please circle the single best answer which describes your service.
A. Basic Life Support
B. Advanced Life Support
C. Both A and B
D. Other (specify)

2. Circle the single best answer which describes your service.

A. Private business
B. Fire service affiliate
C. Special district or local government (other than fire service)
D. Hospital affiliate
E. Other (specify)

3. Circle the level of participation of your service during the exercise.

A. Full Scale Exercise
B. Functional Exercise
C. Tabletop Exercise
D. Communications Exercise

4. Objective I: Did you activate your emergency operations plan and the incident command
system?

Fully met Partially met Did not meet Not applicable/Not Exercised

5. Objective II: Did you establish communications with the OA medical and health point of
contact for guidance and protocols on response activities?

Fully met Partially met Did not meet Not applicable/Not Exercised

6. Objective III: Did you exercise the transportation of infectious patients and infection
control measures?

Fully met Partially met Did not meet Not applicable/Not Exercised

7. Objective IV: Did you exercise the triage, management, and coordination of a large
number of patients, including protocols for determining primary and alternative patient
transportation destinations?

Fully met Partially met Did not meet Not applicable/Not Exercised

8. Objective V: Did you assess the ability to sustain, maximize, and augment EMS staffing
during a surge event?

Fully met Partially met Did not meet Not applicable/Not Exercised

124
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

Ambulance Provider Exercise Evaluation Questions

9. Objective VI: Did you assess the ability to provide prophylaxis to EMS staff, in
coordination with the local public health department?

Fully met Partially met Did not meet Not applicable/Not Exercised

10. Did you extract various “modules” from the 12-hour exercise scenario to create an
exercise for your organization to meet your exercise objectives?
A. Yes, we used multiple modules to create our own exercise.
B. No, we used the scenario as written.
C. Don’t know.

11. Did you conduct a shift change during the exercise?

A. Yes
B. No
C. Don’t know

12. Did you conduct incident action planning in the command center/EOC?
A. Yes
B. No
C. Don’t know

13. Did you conduct a media briefing/press conference during the exercise?
A. Yes
B. No
C. Don’t know

14. What other community response partners did you exercise with? (Check all that apply)
Area hospitals Community clinics Local public health Local OES
EMS Providers Law Enforcement Long-term Care Facilities
Coroner/medical examiner Terrorism Early Warning groups
911 dispatch centers Local school districts
Non-governmental agencies (e.g., American Red Cross, religious organizations)
Other: (specify)

15. Was the guidebook useful in planning your exercise?

A. Yes
B. No
C. Don’t know

16. Was the scenario realistic and allow for testing of the surge/emergency operations plan?
A. Yes
B. No
C. Don’t know

125
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

Ambulance Provider Exercise Evaluation Questions

17. How many total hours did you conduct an exercise in your organization?
A. 1 - 4 hours
B. 5 - 6 hours
C. 7 - 8 hours
D. 8 - 10 hours
E. 11 - 12 hours

18. What time did you exercise (check all that apply)?
0500–0700 0700-0900 0900-1100 1100-1300

1300-1500 1500-1700 Other:

19. Did you receive the exercise scenario intelligence messages disseminated on 10-22 and
10-24-07?

A. No, the messages were injected by the hospital.

B. Yes. The information originated from:

20. The Statewide Medical and Health Disaster Exercise is conducted annually in the fall.
There is a recommendation to move the exercise to Spring (April or May) instead of the
fall each year. This would allow medical and health providers to exercise collaboratively,
but to also avoid conflicts with Golden Guardian and other annual fall events. Would you
support this change and exercise in Spring?

A. Yes, I would support a Spring exercise and participate

B. No, I would not support a Spring exercise, leave the exercise in the fall
C. Other (describe on back of Master Answer Sheet)

Additional Comments and Recommendations?

Please write additional comments on the back of the Master Answer Sheet and attach
additional pages as needed. We very much appreciate your feedback!

Complete the Master Answer Sheet on page 123 and mail to:

Emergency Medical Services Authority

1930 9th Street
Sacramento, CA 95814
Attn: Statewide Exercise Evaluation

126
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

LOCAL PUBLIC HEALTH DEPARTMENT

MASTER ANSWER SHEET
PAGE 1 OF 2
Complete this Master Answer Sheet for responses to the Local Public Health Department
Exercise Evaluation Questions and ONLY THESE TWO PAGES to the address below.
NOTE: THESE MAY BE COMPLETED ON THE COMPUTER AND PRINTED

Local Public Health Department Name: _

Address: _

City: Zip: _

Operational Area: (See map on page 152)

Disaster Coordinator/Evaluator Name: _

Telephone #: Fax #: _

E-mail: _

CHECK THE APPROPRIATE ANSWER

Question 1: A B C D

Question 2: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 3: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 4: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 5: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 6: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 7: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 8: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 9: Fully met Partially met Did not meet Not applicable/Not Exercised

Question 10: A B C

Question 11: A B C

Question 12: A B C

Question 13: A B C

127
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007
LOCAL PUBLIC HEALTH DEPARTMENT
MASTER ANSWER SHEET
PAGE 2 OF 2

NAME OF FACILITY:

Question 14:
Area hospitals Community clinics Local public health Local OES
EMS Providers Law Enforcement Long-term Care Facilities
Coroner/medical examiner Terrorism Early Warning groups
911 dispatch centers Local school districts
Non-governmental agencies (e.g., American Red Cross, religious organizations)
Other: (specify)

Question 15: A B C

Question 16: A B C

Question 17: A B C D E

Question 18: 0500–0700 0700-0900 0900-1100 1100-1300

1300-1500 1500-1700 Other:

Question 19: A. No, the messages were injected by the hospital.

B. Yes. The information originated from:

Question 20: A B C

Mail by NOVEMBER 29, 2007 to:

Emergency Medical Services Authority

1930 9th Street
Sacramento, CA 95814
Attn: Statewide Exercise

128
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

LOCAL PUBLIC HEALTH DEPARTMENT EXERCISE EVALUATION QUESTIONS

Please use the attached Master Answer Sheet when recording your responses. Be sure to
complete every question before submitting the Master Answer Sheet (page 128). Certificates
for Participation will be provided only upon receipt of the 2007 Exercise Participation Evaluation
Master Answer Sheet.

1. Please indicate the level of participation of your clinic during the exercise. (See
Glossary on Page 133 for definitions of exercises.)
A. Full Scale Exercise
B. Functional Exercise
C. Tabletop Exercise
D. Communications Exercise

2. Objective I: Did you activate the department’s emergency operations plan and the
incident command system?

Fully met Partially met Did not meet Not applicable/Not Exercised

3. Objective II: Did you exercise the surge plan for the Public Health Laboratory and/or
Laboratory Response Network (LRN), including specimen transport, agent identification,
chain of custody procedures?

Fully met Partially met Did not meet Not applicable/Not Exercised

4. Objective III: Did you exercise the decision-making and procedures required for the
community and healthcare providers to provide prophylaxis during the biological surge
event?

Fully met Partially met Did not meet Not applicable/Not Exercised

5. Objective IV: Did you assess your ability to provide prophylaxis for public health staff
and essential personnel?

Fully met Partially met Did not meet Not applicable/Not Exercised

6. Objective V: Did you exercise policies and procedures to communicate with hospital
laboratories about proper procedures for sample preparation and shipment to the
Laboratory Response Network (LRN); and, LRN notification of the State Laboratory?

Fully met Partially met Did not meet Not applicable/Not Exercised

7. Objective VI: Did you assess the decision-making processes and procedures for
establishing community-based alternate care sites?

Fully met Partially met Did not meet Not applicable/Not Exercised

129
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

LOCAL PUBLIC HEALTH DEPARTMENT EXERCISE EVALUATION QUESTIONS

8. Objective VII: Did you coordinate and disseminate information in collaboration with the
OA Joint Information Center and in collaboration with local emergency managers,
healthcare providers, and other officials?

Fully met Partially met Did not meet Not applicable/Not Exercised

9. Objective VIII: Did you access and transmit information to regional and state medical
and health authorities through CAHAN and to local healthcare providers through local
communication systems?

Fully met Partially met Did not meet Not applicable/Not Exercised

10. Did you extract various “modules” from the 12-hour exercise scenario to create an
exercise for your organization to meet your exercise objectives?
A. Yes, we used multiple modules to create our own exercise.
B. No, we used the scenario as written.
C. Don’t know.

11. Did you conduct a shift change during the exercise?

A. Yes
B. No
C. Don’t know

12. Did you conduct and document incident action planning in the command center/EOC?
A. Yes
B. No
C. Don’t know

13. Did you conduct a media briefing/press conference during the exercise?
A. Yes
B. No
C. Don’t know

14. What other community response partners did you exercise with? (Check all that apply)
Area hospitals Community clinics Local public health Local OES
EMS Providers Law Enforcement Long-term Care Facilities
Coroner/medical examiner Terrorism Early Warning groups
911 dispatch centers Local school districts
Non-governmental agencies (e.g., American Red Cross, religious organizations)
Other: (specify)

15. Was the guidebook useful in planning your exercise?

A. Yes
B. No
C. Don’t know

130
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

LOCAL PUBLIC HEALTH DEPARTMENT EXERCISE EVALUATION QUESTIONS

16. Was the scenario realistic and allow for testing of the surge/emergency operations plan?
A. Yes
B. No
C. Don’t know

17. How many total hours did you conduct an exercise in your facility?
A. 1 - 4 hours
B. 5 - 6 hours
C. 7 - 8 hours
D. 8 - 10 hours
E. 11 - 12 hours

18. What time did you exercise (check all that applies)?

0500–0700 0700-0900 0900-1100 1100-1300

1300-1500 1500-1700 Other:

19. Did you receive the exercise scenario intelligence messages disseminated on 10-22 and
10-24-07?

A. No, the messages were injected by the hospital.

B. Yes. The information originated from:

20. The Statewide Medical and Health Disaster Exercise is conducted annually in the fall.
There is a recommendation to move the exercise to Spring (April or May) instead of the
fall each year. This would allow medical and health providers to exercise collaboratively,
but to also avoid conflicts with Golden Guardian and other annual fall events. Would you
support this change and exercise in Spring?

A. Yes, I would support a Spring exercise and participate

B. No, I would not support a Spring exercise, leave the exercise in the fall
C. Other (describe on back of Master Answer Sheet)

Additional Comments and Recommendations?

Please write additional comments on the back of the Master Answer Sheet and attach additional
pages as needed. We very much appreciate your feedback!

Complete the Master Answer Sheet on page 128 and mail to:
Emergency Medical Services Authority
1930 9th Street
Sacramento, CA 95814
Attn: Statewide Exercise Evaluation

131
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

Glossary and Acronyms

132
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

Glossary of Terms
Alternate care sites are areas designated to care for patients
which are not normally used for patient care. They can be
Alternate Care Sites hospital or community-based. The sites may be established for
(ACS) patients who need more extensive care such as hydration,
ventilatory assistance, or pain management, or for minor or
episodic care. ACS can also be used to cohort patients with the
same infectious disease or exposure.
The Auxiliary Communications Service (ACS) is an emergency
communications unit who provide State and local government
with a variety of professional unpaid [volunteer] skills, including
administrative, technical and operational for emergency tactical,
administrative and logistical communications. ACS works with
agencies and cities within the Operational Area, neighboring
governments and the State OES Region. Its basic mission is the
emergency support of civil defense, disaster response and
Auxiliary recovery with telecommunications resources and personnel.
Communications CARES: California Amateur Radio Emergency Services
Services CARES is specifically tasked to provide amateur radio
(ACS) communications support for the medical and health disaster
response to state government.
RACES: Radio Amateur Civilian Emergency Services
RACES is a local or state government program established by a
civil defense official. It becomes operational by: 1) appointing a
radio officer; 2) preparing a RACES plan; and 3) training and
utilizing FCC licensed amateur radio operators. RACES, whether
part of an ACS or as a stand alone unit, is usually attached to a
state or local government's emergency preparedness office or to
a department designated by that office, such as the sheriff's or
communications department.
The intentional or threatened use of viruses, bacteria, fungi or
Bioterrorism toxins from living organisms to produce death or disease in
humans, animals or plants.
Co-locating a group of persons (patients) experiencing similar
Cohorting symptoms or disease syndrome to provide medical care and/or
isolation.
Convergent volunteers are individuals who come forward to offer
Convergent disaster response and recovery volunteer services during a
Volunteer disaster event. Convergent volunteers are not persons impressed
into service at the scene of an incident. (California definition)
In epidemiology and public health, the identification of index
patients and their contacts; the detection of outbreaks and
Disease Surveillance epidemics; the determination of the incidence and demographics
of an illness; and the policy-making to prevent further spreading of
a disease.

133
 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

Glossary of Terms
Transmission: Droplet transmission involves contact of the
conjunctivae or the mucous membranes of the nose or mouth of a
susceptible person with large-particle droplets (larger than 5 µm in
size) containing microorganisms generated from a person who
has a clinical disease or who is a carrier of the microorganism.
Droplets are generated from the source person primarily during
coughing, sneezing or talking and during the performance of
certain procedures, such as suctioning and bronchoscopy.
Droplet Transmission via large-particle droplets requires close contact
Transmission between source and recipient persons because droplets do not
And remain suspended in the air and generally travel only short
Isolation distances, usually three feet or less, through the air. Since
droplets do not remain suspended in the air, special air handling
and ventilation are not required to prevent droplet transmission.
Droplet Isolation: Place the patient in a private room. When a
private room is not available, place the patient in a room with a
patient(s) who has active infection with the same microorganism
but with no other infection (cohorting). When a private room is not
available and cohorting is not achievable, maintain spatial
separation of at least three feet between the infected patient and
other patients and visitors. Special air handling and ventilation are
not necessary, and the door may remain open. Category IB
A condition of disaster or of extreme peril to the safety of persons
and property caused by such conditions as air pollution, fire,
Emergency flood, hazardous material incident, storm, epidemic, riot, drought,
sudden and severe energy shortage, plant or animal infestations
or disease, an earthquake or volcanic eruption.
The organized analysis, planning, decision making, assignment
Emergency and coordination of available resources to the mitigation of,
Management preparedness for, response to or recovery from emergencies of
any kind, whether from man-made attack or natural sources.
A centralized location from which emergency operations can be
directed and coordinated. The EOC, operated by local, regional,
Emergency state or federal governments, is comprised of multiple agencies,
Operations Center organizations and disciplines to coordinate all aspects of an
(EOC) incident (e.g., law, fire, EMS, health and medical, logistics,
communications, transportation, public works, finance, response
and recovery planners, etc.) The EOC provides support and
coordination of the incident, but does NOT direct the incident
actions.
An infectious disease or condition that attacks many people at the
Epidemic same time in the same geographical area.
The study of the distribution and determinants of health-related
states and events in populations, and the application of this study
Epidemiology to the control of health problems. Epidemiology is concerned with
the traditional study of epidemic diseases caused by infectious
agents, and with health-related phenomena.

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Glossary of Terms

Exposure: Subjected to, or exposed to, a contaminant in an

Exposure Versus unprotected or partially protected manner, but not necessarily
Contamination contaminated by an agent.
Contamination: Contact with a hazardous or infective agent in
an unprotected manner.
Example: if you are in the area where an agent (like Yersinia
pestis) is released, you may be exposed. If you are sprayed
directly with the agent, you are then contaminated.
Full Scale: This type of exercise is intended to evaluate the
operational capability of emergency responders in an interactive
manner over a substantial period of time. It involves the testing of
a major portion of the basic elements existing in the emergency
operations plans and organizations in a stress environment.
Personnel and resources are mobilized.
Functional: The functional exercise is an activity designed to test
or evaluate the capabilities of the disaster response system. It
can take place in the location where the activity might normally
take place, such as the command center or incident command
post. It can involve deploying equipment in a limited, function-
Exercise specific capacity. This exercise is fully simulated with written or
verbal messages.
Tabletop: An exercise which takes place in a classroom or
meeting room setting. Situations and problems presented in the
form of written or verbal questions generate discussions of
actions to be taken based upon the emergency plan and standard
emergency operating procedures. The purpose is to have
participants practice problem solving and resolve questions of
coordination and assignment in a non-threatening format, under
minimal stress.
Communications: The communications exercise is designed to
test and evaluate communication systems, including lines and
methods of communicating during a disaster. Alternative
communication systems can also be tested, including amateur
radio, cell and satellite systems, among others.

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Glossary of Terms

The HSAS was developed by the Department of Homeland

Security in response to Homeland Security Presidential Directive
#3. There are five Threat Conditions, each identified by a
description and corresponding color. The higher the Threat
Condition, the greater the risk of a terrorist attack. Risk includes
both the probability of an attack occurring and its potential gravity.
Threat Conditions are assigned by the Attorney General in
consultation with the Assistant to the President for Homeland
Homeland Security Security.
Advisory System Low Condition (Green). This condition is declared when there is
(HSAS) a low risk of terrorist attacks.
Guarded Condition (Blue). This condition is declared when there
is a general risk of terrorist attacks.
Elevated Condition (Yellow). An Elevated Condition is declared
when there is a significant risk of terrorist attacks. In addition to
the Protective Measures taken in the previous Threat Conditions,
Federal departments and agencies should consider the following
general measures in addition to the Protective Measures that they
will develop and implement:
High Condition (Orange). A High Condition is declared when
there is a high risk of terrorist attacks.
Severe Condition (Red). A Severe Condition reflects a severe
risk of terrorist attacks. Under most circumstances, the Protective
Measures for a Severe Condition are not intended to be sustained
for substantial periods of time.
Formerly the Hospital Emergency Operations Center, the
Hospital Command designated site for the hospital incident management team to
Center oversee operations, assess status, and develop and execute the
(HCC) incident action plan.
HICS is an emergency management system that employs a
Hospital Incident logical, standardized management (command) structure, defined
Command System responsibilities, clear reporting channels and common
(HICS) terminology to assist hospitals in managing the response to and
recovery from planned and unplanned events. HICS is consistent
with the principles of the Incident Command Systems (ICS) and
the National Incident Management System (NIMS.) Information
on HICS can be obtained through the California EMSA at 916-
322-4336 or on the Website at www.emsa.ca.gov/hics/hics.asp
The nationally used standardized on-scene emergency
management concept is specifically designed to allow its user(s)
to adopt an integrated organizational structure equal to the
Incident Command complexity and demand of single or multiple incidents without
System being hindered by jurisdictional boundaries. ICS is the
(ICS) combination of facilities, equipment, personnel, procedures and
communications operating within a common organizational
structure, with the responsibility of managing resources to
effectively accomplish stated objectives pertinent to an incident.

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Glossary of Terms

Influenza-like-illness is defined as fever (>100° F [37.8° C], oral or

Influenza-Like-Illness equivalent) AND cough, and/or sore throat (in the absence of a
(ILI) KNOWN cause other than influenza. This term/case definition is
used by the CDC and CDPH in surveillance.)
All respirators relying on a mask-to-face seal need to be checked
annually with either qualitative or quantitative methods to
determine whether the mask provides an acceptable fit to a
wearer. The qualitative fit test procedures rely on a subjective
Fit Testing sensation (taste, irritation, smell) of the respirator wearer to a
particular test agent while the quantitative fit test measures face
seal leakage. The relative workplace exposure level determines
what constitutes an acceptable fit and which fit test procedure is
required. (OSHA 29 CFR 1910.139)
The interval between exposure to infection and the appearance of
Incubation Period the first symptom.
The “intelligence community” includes all military, federal, state,
and local Intelligence agencies that collect, analyze report and
disseminate information related to law enforcement, terrorism and
Intelligence homeland security matters. Federal agencies include the Central
Community Intelligence Agency (CIA), Federal Bureau of Investigation (FBI),
and Department of Homeland Security (DHS). State and local
agencies include the California Office of Homeland Security
(OHS), State Terrorism Threat Assessment Center (STTAC),
Regional Terrorism Threat Assessment Center (RTTAC), and
local Terrorism Early Warning Groups (TEWG).
The MHOAC is responsible for coordinating mutual aid resource
Medical and Health requests, facilitating the development of local medical/health
Operational Area response plans and implementing the medical/health plans during
Coordinator a disaster response. During a disaster, the MHOAC directs the
(MHOAC) medical/health branch of the Operational Area EOC and
establishes priorities for medical/health response and requests.

N-95 Mask See “Respirator, N-95”

An intermediate level of the State emergency services
Operational Area organization, consisting of a county and all political subdivisions
within the county.
An epidemic over a wide geographic area and affecting a large
Pandemic proportion of the population, such as pandemic influenza.

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Glossary of Terms

A disease caused by Yersinia pestis (Y. pestis): a gram negative,

bacterium, rod-shaped, found in rodents and their fleas in many
areas around the world. Clinical syndromes caused by Y. pestis
infection include:
-Bubonic plague
-Primary septicemic plague
-Primary pneumonic plague
Plague -Plague meningitis
-Plague pharyngitis
-Pestis minor
-Subclinical infections
As a bioterrorist agent, as in this scenario, it could be used in an
aerosolized form. This most likely would cause primary plague
pneumonia. Other clinical syndromes that could result include
pharyngitis, septicemia, and meningitis.
A site where medications or vaccines intended to prevent disease
Point of Dispensing may be given quickly to a large number of people in the event of a
(POD) public health emergency.
The period during which free entry to a country by humans,
animals, plants or agricultural products is prohibited in order to
limit the spread of potentially infectious diseases; the period of
isolation from public contact after contracting a contagious
Quarantine disease, such as rabies. Complete quarantine is the limitation of
the freedom of movement of healthy persons or domestic animals
that have been exposed to a communicable disease for a period
of time equal to the longest incubation period of the disease, in
such a manner as to prevent effective contact with those not so
exposed.
The Regional Emergency Operations Center (REOC) is the first
level facility of the Governor’s Office of Emergency Services to
Regional Emergency manage a disaster. The REOC provides an emergency support
Operations Center staff operating from a fixed facility, which are responsive to the
(REOC) needs of the operational areas and coordinates with the State
Operations Center.
Recent CDC infection control guidance documents provide
recommendations on how health care workers protect themselves
from diseases potentially spread through the air (such as Severe
Acute Respiratory Syndrome or Tuberculosis) by wearing a fit-
tested respirator at least as protective as a National Institute for
Respirators Occupational Safety and Health (NIOSH)-approved N-95
N-95 respirator. An N-95 respirator is one of nine types of disposable
particulate respirators. Particulate respirators are also known as
"air-purifying respirators" because they protect by filtering
particles out of the air you breathe. Workers can wear any one of
the particulate respirators for protection against diseases spread
through the air- if they are NIOSH approved and if they have been
properly fit-tested and maintained.

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Glossary of Terms
The measures taken to contain respiratory secretions for all
individuals with signs and symptoms of a respiratory infection,
Respiratory including a cough. Measures include: Cover the nose/mouth
Hygiene/Cough when coughing or sneezing; Use tissues to contain respiratory
Etiquette secretions and dispose of them in the nearest waste receptacle
after use; Perform hand hygiene (e.g., hand washing with non-
antimicrobial soap and water, alcohol-based hand rub, or
antiseptic handwash) after having contact with respiratory
secretions and contaminated objects/materials.
The California Sentinel Provider Influenza Surveillance Program
is a partnership between clinicians, local health departments, the
California Department of Public Health, and the federal Centers
Sentinel Provider for Disease Control and Prevention (CDC) to conduct surveillance
for influenza-like illness (ILI). The information collected by
California sentinel providers is combined with other influenza
surveillance data on influenza-related hospitalizations, antiviral
usage, severe pediatric influenza cases and positive laboratory
detections from collaborating hospital, academic and public health
laboratories throughout the state to monitor the timing, location,
and impact of influenza viruses year-round. For more information
on the Sentinel Provider Program, visit
www.dhs.ca.gov/ps/dcdc/VRDL/html/FLU/Flu-sentinel.htm.
SEMS is the emergency management system identified by
Standardized Government code 8607 for managing emergency response to
Emergency multi-agency or multi-jurisdictional operations. SEMS includes the
Management System use of the Incident Command System and is intended to
(SEMS) standardize response to emergencies in California.
The SOC is established by OES to oversee, as necessary, the
State Operations REOC, and is activated when more than one REOC is opened.
Center (SOC) The SOC establishes overall response priorities and coordinates
with federal responders.
An organization of local, state and federal law enforcement
officials together with public and private organizations to detect,
Terrorism Early deter, and respond to terrorist threats. Its primary goal is to
Warning Group detect and prevent planned acts of violence through enhanced
(TEWG) analytical capabilities. The TEW will provide a means for more
complete and productive exchange and analysis of information
between agencies and across disciplines. This initiative also
involves a business and community outreach program that
provides preparedness information and resources.
The Universal Adversary is identified in an exercise as an abstract
Universal Adversary entity used for the purposes of simulation.

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Acronyms
AAR After-Action Report
ACS Alternate Care Sites
ACS Auxiliary Communications Services
AEOC Area Emergency Operations Center
ARC American Red Cross
ASPR Assistant Secretary of Preparedness and Response (Office of)
BVM Bag-Valve-Mouth
CAHAN California Health Alert Network
CAP Corrective Action Plan (formerly known as Corrective Improvement Plan)
CERT Community Emergency Response Team
CBO Community Based Organization
CDC Centers for Disease Control and Prevention
California Department of Public Health (formerly known as the California
CDPH Department of Health Services)
CHA California Hospital Association
CIA Central Intelligence Agency
CIP Corrective Improvement Plan (Now known as Corrective Action Plan)
CISM Critical Incident Stress Management
DHS Department of Homeland Security
DOC Departmental Operations Center
EC Environment of Care
ED Emergency Department
EMS Emergency Medical Services
EMSA Emergency Medical Services Authority
EOC Emergency Operations Center
ETA Estimated Time of Arrival
FBI Federal Bureau of Investigation
FEMA Federal Emergency Management Agency
HCC Hospital Command Center
Hospital Emergency Incident Command System (updated 9-06 and now
HEICS known as HICS)
HEOC Hospital Emergency Operations Center (now known as HCC)
HICS Hospital Incident Command System
HRSA Health Resources and Services Administration (now known as ASPR)
HSAS Homeland Security Advisory System
HVAC Heating, Ventilation and Air Conditioning
IAP Incident Action Plan
IC Incident Command or Incident Commander
ICS Incident Command System
ILI Influenza-like-illness
Joint
Commission Joint Commission on Accreditation of Healthcare Organizations
JEOC Joint Emergency Operations Center
JIC Joint Information Center
LEMSA Local EMS Agency
MHOAC Medical Health Operational Area Coordinator
MOB Medical Office Building

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MRC Medical Reserve Corps

MSELs Master Sequence of Events Listing
NDMS National Disaster Medical System
NIMS National Incident Management System
OA Operational Area
OES (California Governor’s) Office of Emergency Services
OHS (Governor’s) Office of Homeland Security (State of California)
PIO Public Information Officer
POC Point of Contact
POD Point of Dispensing
REOC Regional Emergency Operations Center
RDMHC Regional Disaster Medical Health Coordinator
RDMHS Regional Disaster Medical Health Specialist
RIMS Response Information Management System
RN Registered Nurse
RTTAC Regional Terrorism Threat Assessment Center
SEMS Standardized Emergency Management System
SOC State Operations Center
STTAC State Terrorism Threat Assessment Center
TEW Terrorism Early Warning
TEWG Terrorism Early Warning Group
UA Universal Adversary

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Plague FAQ

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Frequently Asked Questions (FAQ) About Plague

CDC: http://www.bt.cdc.gov/agent/plague/faq.asp
April 5, 2005

What is plague?
Plague is a disease caused by Yersinia pestis (Y. pestis), a bacterium found in rodents and their fleas in
many areas around the world.

Why are we concerned about pneumonic plague as a bioweapon?

Yersinia pestis used in an aerosol attack could cause cases of the pneumonic form of plague. One to six
days after becoming infected with the bacteria, people would develop pneumonic plague. Once people
have the disease, the bacteria can spread to others who have close contact with them. Because of the
delay between being exposed to the bacteria and becoming sick, people could travel over a large area
before becoming contagious and possibly infecting others. Controlling the disease would then be more
difficult. A bioweapon carrying Y. pestis is possible because the bacterium occurs in nature and could be
isolated and grown in quantity in a laboratory. Even so, manufacturing an effective weapon using Y.
pestis would require advanced knowledge and technology.

Is pneumonic plague different from bubonic plague?

Yes. Both are caused by Yersinia pestis, but they are transmitted differently and their symptoms differ.
Pneumonic plague can be transmitted from person to person; bubonic plague cannot. Pneumonic plague
affects the lungs and is transmitted when a person breathes in Y. pestis particles in the air. Bubonic
plague is transmitted through the bite of an infected flea or exposure to infected material through a break
in the skin. Symptoms include swollen, tender lymph glands called buboes. Buboes are not present in
pneumonic plague. If bubonic plague is not treated, however, the bacteria can spread through the
bloodstream and infect the lungs, causing a secondary case of pneumonic plague.

What are the signs and symptoms of pneumonic plague?

Patients usually have fever, weakness, and rapidly developing pneumonia with shortness of breath, chest
pain, cough, and sometimes bloody or watery sputum. Nausea, vomiting, and abdominal pain may also
occur. Without early treatment, pneumonic plague usually leads to respiratory failure, shock, and rapid
death.

How do people become infected with pneumonic plague?

Pneumonic plague occurs when Yersinia pestis infects the lungs. Transmission can take place if
someone breathes in Y. pestis particles, which could happen in an aerosol release during a bioterrorism
attack. Pneumonic plague is also transmitted by breathing in Y. pestis suspended in respiratory droplets
from a person (or animal) with pneumonic plague. Respiratory droplets are spread most readily by
coughing or sneezing. Becoming infected in this way usually requires direct and close (within 6 feet)
contact with the ill person or animal. Pneumonic plague may also occur if a person with bubonic or
septicemic plague is untreated and the bacteria spread to the lungs.

Does plague occur naturally?

Yes. The World Health Organization reports 1,000 to 3,000 cases of plague worldwide every year. An
average of 5 to 15 cases occur each year in the western United States. These cases are usually
scattered and occur in rural to semi-rural areas. Most cases are of the bubonic form of the disease.
Naturally occurring pneumonic plague is uncommon, although small outbreaks do occur. Both types of
plague are readily controlled by standard public health response measures.

Can a person exposed to pneumonic plague avoid becoming sick?

Yes. People who have had close contact with an infected person can greatly reduce the chance of
becoming sick if they begin treatment within 7 days of their exposure. Treatment consists of taking
antibiotics for at least 7 days.

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Frequently Asked Questions (FAQ) About Plague

How quickly would someone get sick if exposed to plague bacteria through the air?
Someone exposed to Yersinia pestis through the air—either from an intentional aerosol release or from
close and direct exposure to someone with plague pneumonia—would become ill within 1 to 6 days.

Can pneumonic plague be treated?

Yes. To prevent a high risk of death, antibiotics should be given within 24 hours of the first symptoms.
Several types of antibiotics are effective for curing the disease and for preventing it. Available oral
medications are a tetracycline (such as doxycycline) or a fluoroquinolone (such as ciprofloxacin). For
injection or intravenous use, streptomycin or gentamicin antibiotics are used. Early in the response to a
bioterrorism attack, these drugs would be tested to determine which is most effective against the
particular weapon that was used.

Would enough medication be available in the event of a bioterrorism attack involving

pneumonic plague?
National and state public health officials have large supplies of drugs needed in the event of a
bioterrorism attack. These supplies can be sent anywhere in the United States within 12 hours.
What should someone do if they suspect they or others have been exposed to plague?
Get immediate medical attention: To prevent illness, a person who has been exposed to pneumonic
plague must receive antibiotic treatment without delay. If an exposed person becomes ill, antibiotics must
be administered within 24 hours of their first symptoms to reduce the risk of death. Notify authorities:
Immediately notify local or state health departments so they can begin to investigate and control the
problem right away. If bioterrorism is suspected, the health departments will notify the CDC, FBI, and
other appropriate authorities.

How can the general public reduce the risk of getting pneumonic plague from another
person or giving it to someone else?
If possible, avoid close contact with other people. People having direct and close contact with someone
with pneumonic plague should wear tightly fitting disposable surgical masks. If surgical masks are not
available, even makeshift face coverings made of layers of cloth may be helpful in an emergency. People
who have been exposed to a contagious person can be protected from developing plague by receiving
prompt antibiotic treatment.

How is plague diagnosed?

The first step is evaluation by a health worker. If the health worker suspects pneumonic plague, samples
of the patient’s blood, sputum, or lymph node aspirate are sent to a laboratory for testing. Once the
laboratory receives the sample, preliminary results can be ready in less than two hours. Confirmation will
take longer, usually 24 to 48 hours.

How long can plague bacteria exist in the environment?

Yersinia pestis is easily destroyed by sunlight and drying. Even so, when released into air, the bacterium
will survive for up to one hour, depending on conditions.

Is a vaccine available to prevent pneumonic plague?

Currently, no plague vaccine is available in the United States. Research is in progress, but we are not
likely to have vaccines for several years or more.

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Exercise Contacts

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Operational Area Medical & Health Exercise Contacts

(Note: some operational areas may not be participating in the Statewide Exercise in
2007, but remain on this list as a resource for future reference)

CONTACT NAME, TITLE &

COUNTY CONTACT INFORMATION
ADDRESS
Jim Morrissey
Phone: 510-618-2036
Alameda County EMS
Alameda Fax: 510-618-2099
1000 San Leandro Blvd. Ste 100
Email: [email protected]
San Leandro, CA 94577
Doug Buchanan
Alpine, Amador, Disaster Preparedness Coordinator Phone: 209-529-5085
Calaveras, Mountain Valley EMS Fax: 209-529-1496
Stanislaus 1101 Standiford Avenue Email: [email protected]
Modesto, CA 95350
Dr. Mark Lundberg
Phone: 530-538-7581
Health Officer
Butte Fax: 530-538-2165
202 Mira Loma
Email: [email protected]
Oroville, CA 95965
Christine Steinhoff Phone: 530-458-0380
Colusa 251 E. Webster St. Fax: 530-458-4136
Colusa, CA 95932 Email: [email protected]
Dan Guerra
Contra Costa EMS Phone: 925-646-4690
Contra Costa 1340 Arnold Drive, Ste. 126 Fax: 925-646-4379
Martinez, CA 94590 Email: [email protected]
Note: Contra Costa County will exercise a
chemical exposure scenario in 2007
Cindy Henderson
Dept of Health & Human Services Phone: (707) 464-3191 ext. 236
Del Norte Public Health Branch Fax: (707) 465-1792
880 Northcrest Drive Email: [email protected]
Crescent City, CA 95531
(Chris) Phone: 530-621-6252
Chris Weston or Richard Todd Cell: 530-919-0831
Public Health Dept. Preparedness (Todd) 530-621-6505
El Dorado
15 Placerville Drive, Suite J Fax: 530-621-4781
Placerville, CA 95667 Email: [email protected];
[email protected]
Central California
Lee Adley Phone: 559-445-3387
EMS Agency
PO Box 11867 Fax: 559-445-3205
(Fresno, Kings,
Fresno, CA 93775 Email: [email protected]
Madera, Tulare)
Grinnell Norton
Phone: 530-934-6588
Public Health
Glenn Fax: 530-934-6463
240 N. Villa Avenue
Email: [email protected]
Willows, CA 95988

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Operational Area Medical & Health Exercise Contacts

Charlene Pellatz
Humboldt County DHHS Phone: 707-268-2133
Humboldt Public Health Branch Fax: 707-445-6097
529 “I” St. Email:
Eureka, CA 95510 [email protected]
Ryan Kelley Phone: 760-482-2974
Imperial 935 Broadway Fax: 760-336-3903
El Centro, CA 92243 Email: [email protected]
Tamara Cohn Phone: 760-873-7868
Inyo 207A West South Street Fax: 760-873-7800
Bishop, CA 93514 Email: [email protected]
Russ Blind
Phone: 661-868-5201
Senior Coordinator
Kern Fax: 661-322-8453
1400 H Street
Email: [email protected]
Bakersfield, CA 93301
Craig McMillan
Lake Co. Dept. of Health Phone: 707-263-1090
Lake
922 Bevins Court Fax: 707-262-4280
Lakeport, CA 95453 Email: [email protected]
No exercise contact provided.
Please contact your local health
Lassen
department or OES for an
Exercise Contact.
Gertha Benson
Phone: 323-869-8041
Disaster Preparedness Coordinator
Los Angeles Fax: 323-869-8065
5555 Ferguson Drive, Suite 220
Email: [email protected]
Commerce, CA 90022
Randy Saxe Phone: 415-499-6871
Marin 161 Mitchell Blvd., Suite 100 Fax: 415-499-3747
San Rafael, CA 94903 Email: [email protected]
Dana Tafoya
Phone: 209-966-3689
Mountain Valley EMS
Mariposa Fax: 209-966-4929
1101 Standiford Ave, Suite D-1
Email: [email protected]
Modesto, CA 95350
Sam Barnet
Coastal Valley EMS Phone: 707 472-2785/2786
Mendocino
175 South School St. Fax: 707- 707 472-2788
Ukiah, CA 95482 Email: [email protected]
Ron Duran
Phone: 209-381-1260
EMS Specialist
Merced Fax: 209-381-1259
260 E. 15th Street
Email: [email protected]
Merced, CA 95340
No exercise contact provided.
Please contact your local health
Modoc
department or OES for an
Exercise Contact.

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Operational Area Medical & Health Exercise Contacts

Christina DeGeorge
POB 3329 Phone: 760-924-1829
Mono
437 Old Mammoth Rd., #Q Fax: 760-924-1831
Mammoth Lakes, CA 93546 E-mail: [email protected]
John Sherwin
Monterey EMS Phone: 831-755-5013
Monterey 19065 Portola Dr. Ste I Fax: 831-455-0680
Salinas, CA 93908 Email: [email protected]
Note: Monterey County is not participating
in the 2007 Statewide Exercise.
Susan Tam
Assistant Public Health Manager
Phone: 707-253-4199
2344 Old Sonoma Road Bldg G
Napa Fax: 707-253-4199
Napa CA 94558
Email: [email protected]
707-253-4199
Fax 707-253-4880
Phone: (530) 265-7174
Andrea Straatemeier, RN
Fax: 530 271-0837
Nevada 500 Crown Point Circle Ste. 110
Email:
Grass Valley, CA 95945
[email protected]
Shane Foss Phone: 714-628-7671
2644 Santiago Canyon Road Fax: 714-628-7154
Silverado, CA 92676-9719 Email: [email protected]
Orange OR OR
Donna Boston\ Phone: 714-628-7054
2644 Santiago Canyon Road Fax: 714-628-7154
Silverado, CA 92676-9719 Email: [email protected]
Patricia Orme
Phone: : 530.886.3416
HHS Community Health
Placer Fax: 530.889.7198
11484 B Avenue
Email: [email protected]
Auburn, CA 95603
Tina Venable Phone: 530-283-6346
Health Dept. Fax: 530-283-6110
Plumas
PO Box 3140 Email:
Quincy, CA 95971 [email protected]
Britta Barton
3900 Sherman Drive Phone: 951-358-7100
Riverside Riverside CA 92503 Fax: 951-358-7105
Post Office Box 7600 Email: [email protected]
Riverside, CA 92513-7600
Preston Rusch Phone: 916-875-9753
Sacramento Co. EMS Fax: 916-875-9711
Sacramento
9616 Micron Avenue, Suite 635 Email: [email protected]
Sacramento, CA 95827
James Clark
San Benito County EMS Phone: 831-636-4066
San Benito
1111 San Felipe Rd., Ste 102 Fax: 831-636-4037
Holllister, CA 95023 Email: [email protected]

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Operational Area Medical & Health Exercise Contacts

Natalie Kessee Phone: 909-386-9814

BT Coordinator Fax: 909-386-9813
San Bernardino
515 N. Arrowhead Avenue Email:
San Bernardino, CA 92415-0060 [email protected]
Donna Johnson Phone: 619-285-6575
San Diego 6255 Mission Gorge Road Fax: 619-285-6531
San Diego, CA 92120 Email [email protected]
Rebekah Varela Phone: 415-554-2894
San Francisco 101 Grove Street, #324 Fax: 415-554-2552
San Francisco, CA 94102 Email: [email protected]
Phil Cook
Phone: 209-468-6818
San Joaquin EMS
San Joaquin Fax: 209-468-6725
PO Box 1020
Email: [email protected]
Stockton, CA 95201
Bob Neuman, MHOAC/EMS
Administrator Phone: 805-546-8728
San Luis Obispo
712 Fiero Lane #29 Fax: 805-546-8736
San Luis Obispo, CA 93401 Email: [email protected]
Kevin Rose
San Mateo EMS Phone: 650-573-2774
San Mateo
225 37th Avenue Fax: 650-573-2029
San Mateo, CA 94403 Email: [email protected]
Nancy Lapolla
Phone: 805-681-5274
MHOAC/EMS Administrator
Santa Barbara Fax: 805-681-5142
300 North San Antonio Road
Email: [email protected]
Santa Barbara, CA 93110-1316
Michael Clark
Santa Clara EMS Phone: (408) 885-3574
645 South Bascom Avenue Fax: (408) 885-3538
Santa Clara San Jose, CA 95128 Email: [email protected]
Note: Santa Clara is participating in clara.ca.us
Golden Guardian and not in the Statewide
Exercise
Celia Barry Phone: 831-454-4751
Santa Cruz EMS Fax: 831-454-4272
Santa Cruz 1080 Emeline Avenue Email: [email protected]
Santa Cruz, CA 95060 cruz.ca.us
John Duffy
Phone: 530-229-8498
Dept. of Public Health
Shasta Fax: 530-229-5074
2650 Breslauer Way
Email: [email protected]
Redding, CA 96001
No exercise contact provided.
Please contact your local health
Sierra
department or OES for an
Exercise Contact.

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October 25, 2007

Operational Area Medical & Health Exercise Contacts

Lynn Corliss
Emergency Response Coordinator Phone: 530-841-2130
Siskiyou Siskiyou Co Public Health Fax: 530-841-4075
806 S. Main St. Email: [email protected]
Yreka, CA 96097
Michael Modrich
Solano EMS Phone: 707-784-8155
Solano
275 Beck Ave. MS 5 - 240 Fax: 707-421-6682
Fairfield, CA 94533 Email: [email protected]
Kent Coxon
Phone: 707-565-6501
Coastal Valley EMS
Sonoma Fax: 707-565-6510
475 Aviation Blvd., Ste 200
Santa Rosa CA 95403
Email: [email protected]
John DeBeaux
Phone 530-822-7400
Emergency Services Division
Sutter Fax: Call for Number
1130 Civic Center Blvd.
Email: [email protected]
Yuba City, CA 95993
Donna S. Wenz, RN
Phone: 530-527-6824
TCHSA-PHD
Tehama Fax: 530-527-0362
PO Box 400
Email: [email protected]
Red Bluff, CA 96080
Elise Osvold-Doppelhaur, PHN Phone: 530-623-8215
Health Dept. Fax: 530-623-1297
Trinity
PO Box 1470 Email:
Weaverville, CA 96093 [email protected]
Clarence Teem
Phone: 209-533-7460
Tuolumne EMS
Tuolumne Fax: 209-533-7406
20111 Cedar Road North
Email: [email protected]
Sonora, CA 95370
Steve Carroll
Phone: 805-981-5305
Disaster Coordinator
Ventura Fax: 805-981-5300
2220 East Gonzales Road, Ste 130
Email: [email protected]
Oxnard, CA 93036
Roger Clarkson
Yolo OES Phone: 530-666-8930
Yolo
35 North Cottonwood Street Fax: 530-666-8909
Woodland, CA 95698 Email: [email protected]
No exercise contact provided.
Please contact your local health
Yuba
department or OES for an
Exercise Contact.

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Statewide Medical & Health Disaster Exercise
October 25, 2007

OES Mutual Aid Regions Map

Acknowledgements
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 State of California
Statewide Medical & Health Disaster Exercise
October 25, 2007

The California Department of Public Health, Emergency Medical Services

Authority and California Hospital Association would like to thank the Exercise
Planning Workgroup for their contributions to the planning of the 2007 Statewide
Medical and Health Disaster Exercise and development of the
Exercise Guidebook.

Exercise Planning Workgroup Members include:

Gina Anderson, California Department of Public Health

Britta Barton, Riverside County Department of Public Health
Brandon Bond, Kaiser Permanente
Elena Ceja, Kaiser Permanente
Kelly Cheffet, Council of Community Clinics of San Diego
MaryAnn Codeglia, San Ramon Regional Medical Center
Robin Flagg, Kaiser Permanente
Cheri Hummel, California Hospital Association
Lois Husted, Queen of the Valley Medical Center
Zerlyn Ladua, Alameda County Department of Public Health
Mary Massey, Hospital Association of Southern California
Jim Morrissey, Alameda County Department of Public Health
Adam Morrill, Emergency Medical Services Authority
Bebe Pedicini, Sutter Auburn Faith Hospital
Ann Potter, Bay Area SUASI Program
Therese Rymer, University of California, San Diego Medical Center
Sarah Salk, Department of Veterans Affairs
Sonia Shah, Kaiser Permanente
Arnie Spanjers, MD., Kaiser Permanente
Kristina Spurgeon, Kaiser Permanente
Kathy Stevenson, Children’s Hospital of Los Angeles
Dale Thompson, Kaiser Permanente
Caryn Thornburg, ValleyCare Health System
Carol Van Ness, California Department of Public Health
Laura Venegas, Emergency Medical Services Authority

Exercise Project Manager/Contractor:

Cheryl Starling, Kaiser Permanente

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