After Action Report Improvement Plan Treacherous Transport Tabletop Exercise Tri-County Region June 7, 2012 Utah Department of Health
ADMINISTRATIVE HANDLING INSTRUCTIONS 1. The title of this document is The "Treacherous Transport - A Healthcare Coalition Tabletop Exercise - TriCounty" After Action Report. 2. The information gathered in this AAR/IP is classified as For Official Use Only (FOUO) and should be handled as sensitive information not to be disclosed. This document should be safeguarded, handled, transmitted, and stored in accordance with appropriate security directives. 3. At a minimum, the attached materials will be disseminated only on a need-to-know basis and when unattended, will be stored in a locked container or area offering sufficient protection against theft, compromise, inadvertent access, and unauthorized disclosure. 4. Points of Contact: Health Department: Christine Warren Utah Department of Health (Office) 801-273-6663 (E-Mail) christinewarren@utah.gov Exercise Director: Chris Floyd Disaster Resistant Communities Group LLC (Office) 850-241-3565 (E-Mail) chrisfloyd@drc-group.com 2 Page
CONTENTS ADMINISTRATIVE HANDLING INSTRUCTIONS... 2 CONTENTS... 3 EXECUTIVE SUMMARY... 4 SECTION 1: EXERCISE OVERVIEW... 5 Exercise Details... 5 Participant Information... 5 SECTION 2: EXERCISE DESIGN SUMMARY... 7 Exercise Purpose and Design... 7 Exercise Objectives, Capabilities and Activities... 7 Scenario Summary... 8 SECTION 3: ANALYSIS OF CAPABILITIES... 9 SECTION 4: CONCLUSION... 18 APPENDIX A: IMPROVEMENT PLAN... 20 APPENDIX B: PARTICIPANT FEEDBACK (3 THUMBS UP 3 THUMBS DOWN).. 21 APPENDIX C: ACRONYMS... 24 3 Page
EXECUTIVE SUMMARY Treacherous Transport - A Healthcare Coalition Tabletop Exercise - TriCounty was designed and facilitated to test hospital evacuation plans, coordination and agreements with outside agencies. The purpose of this report is to analyze exercise results, identify strengths to be maintained and built upon, identify potential areas for further improvement, and support development of corrective actions. Incorporated in Section 3: Analysis of Capabilities of this After Action Report is a comprehensive listing of each with its associated Major Strengths, Primary Areas for Improvement and Improvement Recommendations 4 Page
Exercise Details SECTION 1: EXERCISE OVERVIEW Exercise Name: Type of Exercise: Treacherous Transport - A Healthcare Coalition Tabletop Exercise - TriCounty Tabletop Exercise Start Date: June 7, 2012 Duration: Location: Sponsor: 2 Hours TriCounty Region Utah Department of Health Program: To assist hospitals to assess their plans and procedures regarding a hazardous materials incident. Purpose: The purpose of the exercise was to test hospital evacuation plans, coordination and agreements with outside agencies. Mission: To provide exercise participants from various agencies the opportunity to work together as a unified team in support of a hospital s response to a hazardous materials incident. Scenario Type: Hazardous Materials Incident Participant Information Participant Location TriCounty Health Department Uintah Care Center Utah Department of Health Uintah Basin Medical Center Ashley Regional Medical Center Indian Health Services Uintah Basin Consolidated Communications Center Ashley Regional Medical Center 5 Page
Basin Clinic Gold Cross Ambulance Center Eastern Division Daggett County Northeastern Counseling Center Inc Uintah County Sheriff s Department Number of Participants 23 6 Page
SECTION 2: EXERCISE DESIGN SUMMARY Exercise Purpose and Design The purpose of the exercise was to test hospital evacuation plans, coordination and agreements with outside agencies. Exercise Objectives, Capabilities and Activities Capabilities-based planning allows for the exercise planning team to develop exercise objectives and observe exercise outcomes through a framework of specific action items that were derived from the Target Capabilities List (TCL). The capabilities listed below form the foundation for the organization of all objectives and observations in this exercise. Additionally, each capability is linked to several corresponding activities and tasks to provide additional detail. Based upon the identified exercise objectives below, the exercise planning team decided to demonstrate the following capabilities during this exercise: Communications Activity # 1 Initial Incident Communication # 2 Hospital Command Center Activation and Management # 3 Notification and Coordination with Outside Partners # 4 Return to Normal Operations HazMat Response and Decontamination Activity # 1 Limiting Access to Hospital # 2 Decontamination Evacuation and Shelter-In-Place Activity # 1 Evacuate Patients in Affected Area of Facility # 2 Continue Patient Care Memoranda of Understanding and Agreements 7 Page
Activity # 1 Review Current Agreements with Outside Agencies Scenario Summary It is a warm summer day in June with low humidity and mild breeze out of the west. At 4:30 PM, as rush hour is beginning, a tanker tractor-trailer carrying hazardous materials was cut off by a mini-van driven by a distracted teenager, who was carrying his three younger siblings. The tractor-trailer hit the mini-van and swerved into a ditch, tipping on its side and spilling its contents. 8 Page
SECTION 3: ANALYSIS OF CAPABILITIES Communications Performance [OVERALL] Activity # 1: Initial Incident Communication Associated Critical Tasks Task # 1.1: Have understanding of response agency notifications. Strong Evaluator # 1 Adequate Evaluator # 2 Recommendations Response with EMS, Fire-hazmat and hospitals good. No notification of local clinic / urgent care clinic or local physicians. Totally dependent on regional dispatch and monitoring of dispatch radio. Afterthought notification of County Emergency Manager and trucking company involved (would have accessed their HAZMAT management team for the specific chemicals.) No mention of National Guard CST team. Written checklist of response agencies to be contacted - especially for HAZMAT. Establishment of Code Red notification of local medical community. Task # 1.2 Communications between the field and the hospital. Strong Evaluator # 1 Strong Evaluator # 2 9 Page
Procedure via radio well established through ambulance protocols and essentially unchanged for MCI. Performance [OVERALL] Activity # 2: Hospital Command Center Activation and Management Associated Critical Tasks Task # 2.1: Established protocols for activating the Hospital Command Center. Adequate Evaluator # 1 Strong Evaluator # 2 ED supervisor and facilities management well aware of point at which hospital HCC would be activated. Hospital staff did not automatically mention HCC activation, but when the issue was brought up, procedure appeared to be clearly understood. Visible reminder of trigger points for HCC? Task # 2.2: Hospital Command Center is adequately staffed. Adequate Evaluator # 1 Strong Evaluator # 2 Staff immediately aware of who needed to be involved in HCC. Task # 2.3: Hospital Command Center is able to receive requests for 10 Page
resources/information and dispatch accordingly. Adequate Evaluator # 1 Adequate Evaluator # 2 Both hospitals currently involved in Utah's HAvBed (UHARMS) bed availability system with excellent response time. PIO would request what information was to be released, but unclear how responsive the system would be to news media or public information needs. Hospital would appear to operate in an information silo. Recommendations Need for collaboration with other agency PIOs to create JIC and provide support for hospital and other agency reporting needs. And public need for one voice for information. Task # 2.4: Significant events or developments are communicated to the HCC in a timely fashion. Strong Evaluator # 1 Unsure Evaluator # 2 Initial contact strong. Not clear how information (internal and external) would continue to be gathered and transmitted to HCC. It may depend on who is in ED. Performance [OVERALL] Activity # 3: Notification and Coordination with Outside Partners Associated Critical Tasks 11 Page
Task # 3.1: Maintain communications with outside partner agencies. Strong Evaluator # 1 Adequate Evaluator # 2 Recommendations Strong communication via dispatch radio with EMS and Public Safety. Communication with County Emergency Manager and others made through dispatch. If communication not available through dispatch not sure how it would occur. Less dependence on communication through dispatch. Identify other communications that would be more effective directly: e.g. hospital to hospital, hospital to MRC. Performance [OVERALL] Activity # 4: Return to Normal Operations Associated Critical Tasks Task # 4.1: Communicate return of normal operations to all parties involved. Adequate Evaluator # 1 Weak Evaluator # 2 Recommendations Notification of other hospital on alert, when ED was closed, and when the ED was open again. No notification to agencies not monitoring dispatch-based radio communications. No communication of return to normal operations to the public. Joint Information System of regional PIO cooperative effort would expedite distribution of information to public, news agencies and other agencies. 12 Page
Evaluator Number Evaluator Name # 1 Darrin Brown # 2 Sharon Weyland HazMat Response and Decontamination Performance [OVERALL] Activity # 1: Limiting Access to Hospital Associated Critical Tasks Task # 1.1: Hospital understands and has ability to implement a limited access. Adequate Evaluator # 1 Strong Evaluator # 2 Immediate communications with engineer to shut down HVAC and lock down admission to hospital except at alternate decon entry. Set up decon tent. Check for staff IDs. Performance [OVERALL] Activity # 2: Decontamination Associated Critical Tasks Task # 2.1: Understanding of capabilities to decon patients during a hazardous materials incident. Adequate Evaluator # 1 13 Page
Adequate Evaluator # 2 Recommendations Need for decon before entering hospital and tagging system clear shared procedures between hospital and EMS, but not sure what they would do for a large number of people requiring decon. Concern about lack of HAZMAT trained personnel at hospital and EMS due to turnover. Advised by fire that 50 people HAZMAT operations trained and 6 technician trained and available in Uintah County. Train more EMS and hospital personnel and review on annual basis. Set trigger points on size of event that would require requesting help from fire district for hospital on-site decon. Task # 2.2: Determine appropriate decon procedures based on chemical identified. Weak Evaluator # 1 Recommendations The hospital does not have people on staff that have a lot of experience in decon or properties of different chemicals. Agreements with outside sources or at least outside contacts need to be available to them. Adequate Evaluator # 2 Recommendations Called Environmental Health Department (equipment to test material). Ask driver if available UDOT placards. Shipping manifests and MSDS information. What kind of container or vehicle. Review MSDS to determine decontamination procedure generalizable to both chemicals released. Dispatch can look up information and relay to responders. On site availability of HAZMAT field guide. Realization that cannot depend of placarding trucks. Ensure that unprotected individuals do not enter perimeter set up. If in question, contact National Guard CST team. 14 Page
Evaluator Number Evaluator Name # 1 Darrin Brown # 2 Sharon Weyland Evacuation and Shelter-In-Place Performance [OVERALL] Activity # 1: Evacuate Patients in Affected Area of Facility Associated Critical Tasks Task # 1.1: Review established evacuation plan. Adequate Evaluator # 1 Recommendations Clear understanding of evacuation procedure from ED to unaffected area of hospital for patients not contaminated. Procedure for evacuation of hospitalized patients to alternate care site (not hospital) not specified. Verbal agreements complete. No specifications of set up procedure and meeting staffing requirements for alternative care mentioned. Consider long term care facility options for patients requiring that level of care. Identify MRC capability that could support. Consider physical transport of patients if needed. Consider other region hospitals as resources if patients must leave facility. Task # 1.2: Determine need for outside assistance in evacuation. Unsure Evaluator # 1 Not sure this has been considered. MOUs' with school district or trucking companies. Performance [OVERALL] Activity # 2: Continue Patient Care 15 Page
Associated Critical Tasks Task # 2.1: Procedures are established for alternative care for patients arriving at the ED. Weak Evaluator # 1 Diversion to hospital in Roosevelt. Recommendations Also consider urgent care in Vernal and source of increased staffing. Possible: MRC, Roosevelt Hospital, Indian Health Services clinic on the reservation 15 minutes away. Task # 2.2: Hospital directs patients seeking care to adequate community resources or alternatives. Weak Evaluator # 1 Recommendations No public communication established. Diversion on arrival at hospital. EMS initiates diversion of Trauma I or Trauma 2 patients from accident site to trauma hospital on the Wasatch Front by helicopter. Need for JIC support to assist public in case of required diversion. Evaluator Number Evaluator Name # 1 Sharon Weyland Memoranda of Understanding and Agreements Performance [OVERALL] Activity # 1: Review Current Agreements with Outside Agencies Task # 1.1: Review current agreements. Associated Critical Tasks Evaluator Number Evaluator Name 16 Page
# 1 17 Page
SECTION 4: CONCLUSION Exercises such as this one allow personnel to validate training and practice strategic and tactical prevention, protection, response and recovery capabilities in a risk-reduced environment. Exercises are the primary tool for assessing preparedness and identifying areas for improvement, while demonstrating community resolve to prepare for major incidents. Exercises aim to help entities within the community gain objective assessments of their capabilities so that gaps, deficiencies, and vulnerabilities are addressed prior to a real incident. Exercises are the most effective (and safer) means to: Assess and validate policies, plans, procedures, training, equipment, assumptions, and interagency agreements; Clarify roles and responsibilities; Improve interagency coordination and communications; Identify gaps in resources; Measure performance; and Identify opportunities for improvement. This exercise succeeded in addressing all of the above as it provided examples of good to excellent participant knowledge, teamwork, communication and use of plans and procedures while pointing out areas in need of improvement and clarification. Listed below is a summary of the level of performance the Target Capabilities and Tasks evaluated during the exercise. This summary outlines the areas in which the region s hospitals are strong as well as identifying areas that the departments should invest future planning, training and exercise funds on. Communications Activity Performance # 1 Initial Incident Communication [OVERALL] # 2 Hospital Command Center Activation and Management [OVERALL] # 3 Notification and Coordination with Outside Partners [OVERALL] # 4 Return to Normal Operations [OVERALL] HazMat Response and Decontamination Activity Performance 18 Page
# 1 Limiting Access to Hospital [OVERALL] # 2 Decontamination [OVERALL] Evacuation and Shelter-In-Place Activity Performance # 1 Evacuate Patients in Affected Area of Facility [OVERALL] # 2 Continue Patient Care [OVERALL] Memoranda of Understanding and Agreements Activity Performance # 1 Review Current Agreements with Outside Agencies [OVERALL] 19 Page
APPENDIX A: IMPROVEMENT PLAN This Improvement Plan has been developed specifically for Utah Department of Health based on the results of Treacherous Transport - A Healthcare Coalition Tabletop Exercise - TriCounty conducted on June 7, 2012. These recommendations draw on both the After Action Report and the After Action Conference. Capability Observation Recommendation Responsible Agency Completion Date Communications Haz-Mat Response and Decontamination Evacuation and Shelter-In-Place Memorandum of Understanding and Agreements 20 Page
APPENDIX B: PARTICIPANT FEEDBACK (3 THUMBS UP 3 THUMBS DOWN) Thumbs Up Directions were clear and scenario was a potential real event. The information was presented pretty close to how it would be in real life. Questions focused on individual organizations enough to keep participants on track. Communication. Everyone s willingness to attend this exercise to understand everyone s roles and responsibilities as well as a chance to meet face-to-face. Communication between the two hospitals went very well. Communication from the scene to the hospital was quick and the hospital was able to lock down before contaminated bystanders could wander into the hospital Decon was performed at the scene and also set up at the hospital. Learning the order of response to an emergency. Learning the role my organization (Urgent Care) in the case of an emergency. Meeting the people in charge of each organization. Very good participation and the exercise was well represented with many HPP partnerships. Good group discussions. The exercise brought allot of information to the table which will require additional planning, exercising. Communication - The notification appears to be in place. Many were at the exercise and it appeared to be good feedback. The two hospitals appear to have good working relationship. Communication of the event to the hospital staff. Locking down the hospital, getting an outside triage in place, and putting up the decontamination tent. Decontamination of the victims. 21 Page
Communication - The hospital listens to radio traffic and would be aware of the situation early. Decon - Decon was established quickly at seen and at hospital. Responsibility - Different agencies knew their role in the incident. Great group participation. Finding solutions to the problems encountered. Willingness of participants from virtually all ESF # 8 and supporting responders (fire, public safety, county emergency management). Good open discussion. Clarification of resources for support and their extent in the community: sense of strength and ability to deal with a complex emergency as a community and region. Good understanding of procedures for management of a HAZMAT incident on the part of EMS, fire and the hospitals. More specifics on location. Hospital decon is not self-sustainable. Thumbs Down Need for local PIO's to get together to establish procedures. Limited number of decon personnel at both hospitals. With the high temperatures the staff would not have been able to decontaminate patients for more than an hour. Limited staffing at hospitals. A large number of patients would have overwhelmed both facilities. The health department has very limited knowledge of decon. They were suggesting that deconing with water would have been dangerous. Decon may have been delayed and further injury occur while they argued the idea. Information about an emergency needs to be relayed to the Urgent Care so we know how to properly handle patients. Getting a proper protocol and having every one trained on how to handle this kind of emergency situation. Communication between partners. Incorporated the MRC to help with overwhelmed hospitals or first responders. Process for how areas would be sealed off and restricted. 22 Page
Dispatch needed my personal phone number to be able to text notification. Is there a way to get chemical information out to the public. Some of the 20 people had very little input. 4 or 5 monopolized the conversations. Internal communications about the event and when to institute the Command Center. Additional personnel needed to run the decontamination tent for long periods of time. The hospital lacks personnel to perform decon and security. May need better outside agreements. Distance from seen to evacuate was unclear. Didn't know if the hospital would be affected by fumes. Knowledge of how incident command works when multiple command centers are up and running. Better communications with other agencies when coordinating large incidents. Additional staffing during major incidents. More participation in these group exercises. More work on emergency staffing plans within hospitals, especially. MRC suggested for traffic control, assisting with hospital security, rehabilitation. Licensed staff could assist more with medical and technical needs. Over-reliance on dispatch for inter-agency communication. No communications with agencies, providers, individuals that are not connected with the public safety dispatch system. Dispatch resources limited (three positions -- with difficulty of finding qualified personnel.) Need for a Joint Information System to generate a single message line for the event. PIO team composed of agency PIOs to generate the support to meet multiple communications needs within and external to agencies involved -- especially for public communications. 23 Page
APPENDIX C: ACRONYMS Acronym Meaning COMM CONOPS ED EMS EOC ESF IAP IC ICS IMT JIC LOFR MOA MOU MRC NIMS OPS PIO SitRep SOG SOP UC Communications Concept of Operations Emergency Department Emergency Medical Service Emergency Operations Center Emergency Support Function Incident Action Plan Incident Command Incident Command System Incident Management Team Joint Information Center Liaison Officer Memorandum of Agreement Memorandum of Understanding Medical Reserve Corps National Incident Management System Operations Public Information Officer Situation Report Standard Operating Guideline Standard Operating Procedure Unified Command 24 Page