After Action Report/Improvement Plan

MHSPP - MLS Laboratories January 6, through April 23, After Action Report/Improvement Plan July - 1 - MDH-PHL

- 2 - MDH-PHL

Contents Administrative Handling Instructions... 4 Executive Summary... 5 Section 1: Exercise Overview... 6 Section 2: Exercise Design Summary... 10 Section 3: Analysis of Capabilities... 12 Section 4: Conclusion... 16 Appendix A: Improvement Plan... 17-3 - MDH-PHL

Administrative Handling Instructions 1. The title of this document is, MHSPP - MLS Laboratories Specimen Collection, Packaging, After Action Report/Improvement Plan. 2. The attached materials should be disseminated only on a need-to-know basis and should be protected against unauthorized disclosure. 3. Points of Contact: Stefan Saravia Chemical Threat Preparedness MDH PHL 601 Robert Street N St. Paul, MN 55164 651-201 5579 (office) Stefan.saravia@state.mn.us Paula Snippes MLS Program Advisor MDH PHL 601 Robert Street N St. Paul, MN 55164 651-201 5581 (office) Paula.snippes@state.mn.us Maureen Sullivan Emergency Preparedness and Response Supervisor MDH PHL 601 Robert Street N St. Paul, MN 55164 651-201 5582 (office) Maureen.sullivan@state.mn.us - 4 - MDH-PHL

Executive Summary This exercise was designed to assess the capability of Minnesota clinical laboratories to collect, package and ship specimens from individuals who have been exposed to chemicals resulting from a known or unknown terrorist incident or industrial accident. Most participating laboratories were located in facilities that would realistically see an emergency room-type patient. The exercise was designed to evaluate the laboratories knowledge of which specimens to collect, the availability of adequate supplies, and their ability to correctly package the specimens to ensure their integrity during transport. In addition the exercise attempted to evaluate the mode of transportation used by the laboratories to deliver specimens to the Minnesota Department of Health Public Health Laboratory (MDH-PHL). Target Capability: Laboratory Testing and Communications Objectives: 1. Test the Minnesota Laboratory System (MLS) Alert System. 2. Assess the sentinel laboratories familiarity and readiness level for handling an unknown chemical exposure incident. 3. Assess the ability of the sentinel laboratories to properly collect, package and ship specimens to MDH-PHL. 4. Assess the capacity of the courier network to deliver an increased volume of specimens. 5. Test the ability of the laboratories to achieve the benchmarks stated in the time table. 6. Prepare and discuss each laboratory s lessons learned from this exercise and provide feedback to the sentinel laboratories at the MLS Regional Laboratory Conferences. Major Strengths The use of the MDH Chemical Terrorism website for communication and information worked well. Many laboratories found the website to be a valuable tool for finding necessary documents, forms, and contact information. The Minnesota Laboratory System communication system serves as a highly robust means of communicating emergency alerts and notifications with the sentinel laboratories throughout the state of Minnesota. MDH s current procedures and forms for a laboratory response to an unknown chemical exposure event are adequate for a timely response. Primary Areas for Improvement While MDH s current procedures and forms for responding to an unknown chemical exposure event are adequate for a timely response several suggestions were received from participating laboratories for improvement. The exercise highlighted the need to further research several issues regarding chain-ofcustody procedures. Contact information for emergency response personnel at the sentinel laboratories throughout the state needs to be updated. - 5 - MDH-PHL

Section 1: Exercise Overview Exercise Name: MHSPP - MLS Laboratories and Shipping Functional Exercise Type of Exercise: Functional Exercise Exercise Date: Three stages; Stage 1: January 26,, Stage 2: February 2,, Stage 3: February 17 27,, Regional Lab Conferences: April 7-23, Location: The Minnesota Department of Health, Public Health Laboratory as well as 118 hospital based sentinel laboratories throughout the state of Minnesota Sponsor: NA Program: Laboratory Emergency Preparedness and Response Mission: Chemical emergency preparedness Capabilities: Laboratory specimen collection and communication Scenario Type: Unknown chemical exposure event Planning Team Leaders: Stefan Saravia Chemical Threat Preparedness MDH PHL 601 Robert St. N St. Paul, MN 55164 651-201-5579 (office) stefan.saravia@state.mn.us Paula Snippes MLS Program Advisor MDH PHL 601 Robert St. N St. Paul, MN 55164 651-201-5581 (office) paula.snippes@state.mn.us Maureen Sullivan Emergency Preparedness and Response Supervisor MDH PHL 601 Robert St. N St. Paul, MN 55164 651-201-5582 (office) maureen.sullivan@state.mn.us - 6 - MDH-PHL

Participating Organizations Laboratory Name Location Laboratory Name Location ACMC Willmar MeritCare Medical Group Fargo, ND Albany Area Hospital Albany Meritcare Thief River Falls SE Clinic Thief River Falls Albert Lea Medical Center Albert Lea Mille Lacs Health System Onamia Allina Medical Clinic Shakopee Minneapolis Public Health Laboratory Minneapolis Allina Medical Clinic - Coon Rapids Coon Rapids Monticello-Big Lake Hospital Monticello Alllina Medical Laboratories (Abbott-Northwestern, Unity Hospital, Mercy Hospital, United Hospital) Minneapolis Murray County Medical Center Slayton, MN Altru Hospital Grand Forks, ND New Ulm Medical Center New Ulm Appleton Area Health Services Appleton North Country Regional Hospital Bemidji Austin Medical Center Austin North Memorial Medical Center Robbinsdale Avera Marshall Regional Medical Center Marshall North Valley Health Center Warren Avera McKennan Hospital Sioux Falls, SD Northfield Hospital Northfield Avera Worthington Specialty Clinic Worthington Northwest Medical Center Thief River Falls Bigfork Valley Hospital Bigfork Olmsted Medical Center Byron Brainerd Medical Center Brainerd Olmsted Medical Center Hospital Rochester Broadway Medical Center Alexandria Owatonna Clinic/Mayo Health System Owatonna Burnsville Family Physicians Burnsville Owatonna Hospital Owatonna Cambridge Medical Center Cambridge Park Nicollet Methodist Hospital St. Louis Park Cannon Falls Medical Center Cannon Falls Paynesville Area Health Care System Paynesville Indian Health Service Cass Lake Hospital Cass Lake Perham Memorial Hospital and Home Perham CentraCare Laboratory Services Saint Cloud Pipestone County Medical Center Pipestone Central Lakes Medical Clinic P.A. Crosby Queen of Peace Hospital New Prague Children s Hospitals and Clinics of MN Minneapolis Redwood Area Hospital Redwood Falls Clearwater County Memorial Hospital Bagley Regina Medical Center Hastings Community Memorial Hospital Cloquet Regions Hospital St. Paul Community Memorial Hospital Winona Renville County Hospital and Clinics Olivia Cook County North Shore Hospital Grand Marais Rice Memorial Hospital Willmar Cook Hospital Cook Ridgeview Medical Center Waconia Cuyuna Regional Medical Center Crosby River's Edge Hospital and Clinic St. Peter Deer River Healthcare Center Deer River Riverwood Healthcare Center Aitkin Detroit Lakes Clinic Detroit Lakes Sanford Clinic - Mt. Lake Mt. Lake - 7 - MDH-PHL

Laboratory Name Location Laboratory Name Location District One Hospital Faribault Sanford Jackson Medical Center Jackson Douglas County Hospital Alexandria Sanford Laboratories Luverne Luverne Ely Bloomenson Community Hospital Ely Sanford Laboratories Windom Windom Fairmont Medical Center Fairmont Sanford Regional Hospital Worthington Fairview Lakes Regional Healthcare Wyoming Shriners Hospital for Children Minneapolis Fairview Northland Medical Center Princeton Sleepy Eye Medical Center Sleepy Eye Fairview Red Wing Medical Center Red Wing SMDC Clinical Laboratory Duluth Fairview Ridges Hospital Burnsville Springfield Medical Center Mayo Health System Springfield Fairview Southdale Hospital Edina St. Michael s Hospital Sauk Centre Fairview University Medical Center-Mesabi Hibbing St. Cloud VA Medical Center St. Cloud Falls Memorial Hospital International Falls St. Croix Regional Medical Center St. Croix Falls, WI Fergus Falls Medical Group Fergus Falls St. Elizabeth's Medical Center Wabasha First Care Medical Services Fosston St. Francis Healthcare Campus Breckenridge Glacial Ridge Health System Glenwood St. Francis Regional Medical Center Shakopee Glencoe Regional Health Services Glencoe St. Gabriel's Hospital Little Falls Graceville Health Center - Holy Trinity Hospital Graceville St. James Medical Center St. James Grand Itasca Clinic and Hospital Grand Rapids St. John's Hospital Maplewood Granite Falls Hospital Granite Falls St. Joseph's Area Health Services Park Rapids Hennepin County Medical Center Minneapolis St. Joseph's Hospital St. Paul Hutchinson Area Health Care Hutchinson St. Joseph's Medical Center Brainerd Immanuel St. Joseph s Hospital - Mayo Health System Mankato St. Luke's Hospital Duluth Kanabec Hospital Mora St. Mary's Innovis Health Detroit Lakes Kittson Memorial Healthcare Center Hallock St. Paul Ramsey County Public Health St. Paul Lake City Medical Center Lake City Staples Hospital Staples Lake Region Healthcare Fergus Falls State Operated Forensic Services St. Peter Lakeview Hospital Stillwater Stevens Community Medical Center Morris LakeWood Health Center Baudette Swift County Benson Hospital Benson Lakewood Health System Staples TriCounty Hospital Wadena LifeCare Medical Center Roseau Tyler Healthcare Center Tyler Long Prairie Hospital Long Prairie United Family Practice Health Center St. Paul Madelia Hospital Madelia United Hospital District Blue Earth Mahnomen Health Center Mahnomen University of Minnesota Medical Center, Fairview Minneapolis Mankato Clinic, LTD. Mankato University of Minnesota Medical Center, Fairview - Riverside Campus Minneapolis Mayo Clinic Rochester Virginia Regional Medical Center Virginia - 8 - MDH-PHL

Laboratory Name Location Laboratory Name Location McKennan Hospital and University Health Center Sioux Falls, SD Waseca Medical Center Waseca Medical Associates of MN St Paul Wheaton Community Hospital Wheaton Meeker Memorial Hospital Litchfield White Community Hospital Aurora Melrose Area Hospital Centracare Melrose Windom Area Hospital Windom Mercy Hospital & HCC Moose Lake Winona Clinic Winona MeritCare Bemidji Number of Participants 118 laboratories participated in at least one stage of this exercise 118 laboratories participated in Stage 1 112 laboratories participated in Stage 2 89 laboratories participated in Stage 3 114 facilities were represented at the regional conferences 249 individuals attended the regional conferences - 9 - MDH-PHL

Exercise Purpose and Design Section 2: Exercise Design Summary In the event that individuals are exposed to a chemical or chemicals that may pose significant public health concern it is important that health care providers are capable of quickly collecting specimens from the exposed individuals and delivering them to the Public Health Laboratory. The information learned from the analysis of these specimens may be used to steer the direction of the public health response. Specifically, this data can be used to accurately assess the number of individuals exposed to the chemical, determine appropriate treatment of exposed patients, and for potential evidentiary purposes in cases where prosecution of the responsible party may be sought. While several objectives were identified in preparing this exercise, the overarching goal was to test the laboratories ability to collect the proper specimens and deliver them to MDH Public Health Laboratory. We wanted to educate participants on the process for collecting and packaging chemical exposure specimens, including the chain-of-custody and temperature control procedures. This exercise was organized into three stages. The first stage was designed to notify the participants of the upcoming exercise and obtain updated contact information for the MLS database to ensure the appropriate person at each facility was identified to receive subsequent notifications and exercise updates. We gave the participants one week to complete this stage of the exercise before proceeding to Stage 2, which consisted of an on-line survey that measured the availability of supplies that were required to complete the functional part of the exercise. The Stage 2 survey also asked the participants questions about their planned shipping method (e.g. private courier or commercial transporter). By asking these questions, we intended to increase awareness among participants about supplies that would be required and inform decisions on how the specimens would be transported to MDH-PHL. Finally, Stage 3 involved the hospitals packaging and shipping mock specimens to MDH-PHL. This stage tested the laboratories ability to correctly collect the appropriate specimen types, correctly complete the chain-of-custody paperwork, and transport the specimens to meet the applicable specimen quality requirements and shipping regulations. Exercise Scenario Five individuals were admitted to the emergency department complaining of severe diarrhea and vomiting. They informed the emergency department doctor that they had been at the county fair that evening. After the fair ended a group of individuals were walking back to their cars when a crop dusting plane flying overhead dropped a liquid onto the neighboring field. They stated that they thought the plane was rather close to the people to be spraying. They said that as the load was falling to the ground the wind shifted in their direction and they could feel droplets of the liquid hitting their face and hands. They wiped the liquid off with their sleeves and proceeded to drive home, roughly an hour away. On the way to their home the passengers began to - 10 - MDH-PHL

experience symptoms and decided to drive straight to the hospital. The emergency room physician contacted the Minnesota Poison Control Center and was informed that the Minnesota Department of Health may be able to help identify the chemical that these individuals were exposed to. Because it is unknown at this time whether this release was intentional and possibly terrorist related, the physician asks you to collect the Unknown Chemical Exposure Panel from these five individuals. Exercise Objectives, Capabilities, and Activities Objective 1: Test the MLS Alert System Target Capability: Quickly and effectively disseminate information to sentinel laboratories throughout the state of Minnesota using the MLS communication system. Activities: Stage 1 notification served as a means to notify the sentinel laboratories of the upcoming functional exercise. Stage 2 notification included a survey regarding specimen collection, packaging and shipping. Stage 3 notification announced the beginning of the functional portion of the exercise. The final notification marked the end of the exercise and requested evaluation documentation. Evaluation information for this activity was collected on the Exercise Evaluation and Documentation form which was completed by each participating sentinel laboratory. Objective 2: Assess the sentinel laboratories readiness level and familiarity with procedures for an unknown chemical exposure incident. Target Capability: Quickly locate and understand the procedures for collecting, packaging and shipping specimens from individuals that have been exposed to chemical agents, and know to contact the chemical response phone at the MDH-PHL. Activities: Stage 2 of the exercise asked the sentinel laboratories to complete a survey which measured their access to the supplies required to complete the exercise, what method they would use to deliver specimens to the laboratory, where to find the applicable procedures for completing the exercise, and the MDH-PHL emergency contact information. Objective 3: Assess the ability of the sentinel laboratories to properly collect, package and ship specimens to MDH-PHL. Target Capability: Properly collect, package and ship specimens from individuals that have been exposed to chemical agents while preserving the integrity of the evidence through the proper use of chain-of-custody and evidence taping procedures. Activities: Stage 3 of this exercise asked that the sentinel laboratories package and ship specimens from five simulated patients. When receiving the specimens, MDH-PHL staff evaluated this objective through the use of a checklist that was completed for each individual package. In addition, the sentinel labs were asked to self-evaluate their work during this stage of the exercise on the Exercise Evaluation and Documentation form. Objective 4: Assess the capacity of the courier network to deliver an increased volume of specimens. - 11 - MDH-PHL

Target Capability: Test the ability of the courier network that delivers specimens to MDH- PHL to handle an increased volume of samples that may result from a chemical release event. Activities: Many of the participating sentinel laboratories delivered samples to the MDH- PHL for this exercise via a private courier. The ability of the private couriers to respond to this increased sample volume was assessed by tracking the time it took samples to arrive at the laboratory during Stage 3 of the exercise as well as through the Exercise Evaluation and Documentation form. Objective 5: Provide feedback to the sentinel laboratories regarding the exercise and the ability of the laboratories to achieve the benchmarks stated in the time table. Target Capability: Communicate findings from all three stages of the exercise to the sentinel laboratories through regional conference calls following the end of Stage 3, and prepare a summary report for Stage 3 for each participating sentinel lab. Activities: Hot wash conference calls were held for each region the week following their completion of Stage 3 of the exercise. In addition, individualized reports were mailed to each of the sentinel laboratories that participated in Stage 3 of the exercise, summarizing the findings from the assessment tool used to accession the specimens when they arrived at MDH-PHL. Objective 6: Prepare and discuss lessons learned from this exercise at the MLS Regional Laboratory Conferences. Target Capability: Provide a forum for sentinel laboratories to voice concerns and lessons learned about the procedures for collecting, packaging and shipping specimens, and about the exercise as a whole, at the MLS Regional Laboratory Conferences. Activities: Eight regional lab conferences were held in each of the HSPP regions between April 7 and April 23,, with 249 laboratorians in attendance, representing 114 facilities. - 12 - MDH-PHL

Section 3: Analysis of Capabilities Target Capability 1: Quickly and effectively disseminate information to sentinel laboratories throughout the state of Minnesota using the MLS communication system. Observation 1: MDH found that many of the emergency contacts in the MLS database for sentinel laboratories were not the appropriate contacts for a chemical release event. Analysis: Many laboratories have experienced a turn-over in personnel with corresponding changes for the correct MLS contact in each facility. In addition, the MLS database originally focused on the individual at each facility who is responsible for a biological event, which may not necessarily be the individual who would be contacted in a chemical event. Recommendation: Many of the emergency contacts for a chemical event were updated during the exercise. In addition, MDH will be updating the MLS database by asking all sentinel laboratories for updated emergency contact information for all areas within their laboratory, specifically an emergency preparedness contact. Observation 2: During the exercise some laboratories did not receive notification of Stage 3 of the exercise even though they had updated their contact information during Stage 1 of the exercise. Analysis: During the exercise MDH had several people working on summarizing data with several spreadsheets being used simultaneously. The spreadsheet that was finally used as a master list for sending out Stage 3 notification was missing some hospital data. Recommendation: In the future when working on large projects involving multiple people, MDH needs to administer a procedure to ensure the accuracy of data entry. More time needs to be allotted to plan for a more effective IT solution. Observation 3: The MLS communication was an effective means of communication. Analysis: Through evaluation tools used, sentinel laboratories provided feedback that the MLS communication system worked well for notification. Recommendation: MDH-PHL will continue to use the MLS communication system for notification of sentinel laboratories. Target Capability 2: Quickly locate and understand the procedures for collecting, packaging and shipping specimens from individuals that have been exposed to chemical agents including contact information. Observation 1: Many participants provided feedback, via numerous phone calls, regarding the procedures posted for collecting packaging and shipping specimens and the availability of the proper supplies. The key issues that need to be addressed include: Making the documents more clear and concise, perhaps by presenting the material in an SOP or flowchart format. Providing better differentiation between shipping procedures using a private courier versus a commercial transporter. Clarifying the chain-of-custody and evidence preservation procedures. - 13 - MDH-PHL

Analysis: The procedures that MDH posted for the sentinel laboratories were developed by the CDC and then slightly modified to meet MDH needs. It is apparent that the procedures need to be further modified and simplified so that they are more concise and easier to follow. Recommendation: Based on the feedback received throughout the exercise, the procedures and forms will be updated to include the recommendations from the sentinel laboratories. CDC will be consulted when making the updates. Observation 2: The MDH chemical terrorism website was an effective way to provide the protocols to the sentinel laboratories. Analysis: Through several evaluation tools, sentinel laboratories provided feedback that pointed out that the MDH chemical terrorism website was easy to use and a great place to post the protocols and exercise details. Recommendation: MDH will continue to use the website for posting protocols and other reference materials. Target Capability 3: Properly collect, package and ship specimens from individuals that have been exposed to chemical agents while preserving the integrity of the evidence through the proper use of chain-of-custody and evidence taping procedures. Observation 1: Many labs do not have access to dry ice for shipping urine samples. Analysis: In some areas of the state dry ice is not readily available. Recommendation: MDH will follow up with the CDC to determine what their quality requirements are for handling urine specimens that are not frozen during transport. Observation 2: Many labs use a commercial transporter to ship specimens to MDH-PHL and many of these laboratories did not stock the materials required by the US Department of Transportation (DOT) for the transportation of these specimens. Analysis: The sample transportation requirements for the Unknown Chemical Exposure Panel specimens are slightly different than those for sending the routine isolates with which the laboratories are more familiar. The primary differences are the strict temperature receipt requirements including the use of dry ice for temperature control. Recommendation: After collecting feedback from the laboratories it has become apparent that one solution will not work for all laboratories. MDH will work with laboratories that are lacking the required DOT shipping materials to acquire these supplies. MDH will also explore the ideas of putting chemical exposure collection and packaging kits together, as well as the potential for regional stashes of supplies for laboratories to share. Observation 3: Many labs did not fill out the chain-of-custody form properly. Analysis: Design of the form was obviously flawed, which did not facilitate laboratorians in filling it out properly. Recommendation: Chain-of-custody form will be re-designed for better clarity and efficient use. - 14 - MDH-PHL

Observation 4: There was confusion over chain-of-custody protocol, specifically with the question of whether couriers were supposed to be part of the string of custody and if they should sign the form. In addition labs were not sure who was supposed to keep the original chain-of-custody form. Analysis: The CDC chain-of-custody protocol is not clear and does not follow routine chain-of-custody protocols that most labs are familiar with. Recommendation: MDH will contact CDC to clarify the chain-of-custody procedure to better align with routine practices of sentinel laboratories and to clarify the courier s role. Target Capability 4: Test the ability of the courier network that delivers specimens to the Public Health Laboratory to handle an increased volume of samples which may result from a chemical release event. Observation 1: MDH found that many laboratories in the western part of the state rely on a single hospital courier system, which ran out of dry ice and shipping containers during the exercise. Analysis: The courier does not maintain a dry ice capacity to deal with a large volume of frozen specimens. Recommendation: Since many labs rely on the same dry ice supplier that can easily be overwhelmed by a surge in demand, MDH will encourage the sentinel laboratories to locate multiple sources of dry ice. Observation 2: During the exercise a snow storm hit the state which kept several of the couriers from delivering specimens within the specified timeframe. Analysis: Minnesota regularly experiences severe weather which can affect transportation of specimens to the laboratory. Recommendation: Depending on the extent of the weather delay, we may have to accept that samples will be delayed. The safety of individuals deliveing specimens should always take precedence over timely delivery. Target Capability 5: Communicate findings from all three stages of the exercise to the sentinel laboratories through regional conference calls following the end of Stage 3, and prepare a summary report for Stage 3 for each participating sentinel lab. Observation 1: The regional hot wash teleconferences had very poor attendance from the laboratories that were involved in the exercise. Analysis: It is unclear whether the poor attendance by participants was due to scheduling conflicts, a failure to thoroughly read the email notifications, or lack of interest due to exercise fatigue. Recommendation: In the future, conference calls will be included in the exercise time table so that all of the participants will be aware of them from the beginning of the exercise. Observation 2: The regional hot wash provided timely observations from the laboratories. - 15 - MDH-PHL

Analysis: The labs that did attend the calls provided valuable observations immediately after the exercise was played-out. Therefore the information was very robust and provided great material for evaluating the exercise. Recommendation: Schedule hot wash teleconferences after future exercises. Target Capability 6: Provide a forum for attending sentinel laboratories to voice concerns and lessons learned about the procedures for collecting, packaging and shipping specimens, and about the exercise as a whole, at the MLS Regional Laboratory Conferences. Observation 1: Regional conferences effectively provided a forum for discussion about the exercise. Analysis: Recap of the exercise via an interactive presentation by Stefan Saravia, was well received and provided an opportunity for laboratorians to further discuss issues as a region with MDH staff. Recommendation: In future exercises continue to provide interactive presentations at the regional conferences to facilitate discussion. Section 4: Conclusion This exercise was extremely beneficial for the Public Health Laboratory and, based on feedback received, it was also beneficial for the sentinel laboratories. This was the first functional laboratory exercise in Minnesota that tested the procedures for collecting and sending specimens to the MDH-PHL following a chemical exposure event. MDH received excellent suggestions from the participating laboratories for ways to improve the procedures, and plans are in place to incorporate those suggestions into the revised plans. - 16 - MDH-PHL

Appendix A: Improvement Plan - 17 - MDH-PHL

Capability 1. Quickly and effectively disseminate information to sentinel laboratories throughout the state of Minnesota using the MLS communication system. Observation Title 1.1. MDH found that many of the emergency contacts in the MLS database for sentinel laboratories were not the appropriate contacts for a chemical release event. 1.2. During the exercise some laboratories did not receive notification of Stage 3 of the exercise even though they had updated their contact information during Stage 1 of the exercise. Recommend ations 1.1.1. Many of the emergency contacts for a chemical event were updated during the exercise. In addition, MDH will be updating the MLS database by asking all sentinel laboratories for updated emergency contact information for all areas within their laboratory, specifically an emergency preparedness contact. 1.2.1. Based on the feedback received throughout the exercise, the procedures and forms will be updated to include the recommendati ons from the sentinel laboratories. CDC will be Corrective Action Description Capability Element Communications Primary Responsible Agency MDH-PHL Agency POC MLS Program Planning MDH-PHL CT Start Date May 1, May 1, Completion Date September, September, 18

Capability 2. Quickly locate and understand the procedures for collecting, packaging and shipping specimens from individuals that have been exposed to chemical agents including contact information. Observation Title 1.3. The MLS communication was an effective means of communication. 2.1. Many participants provided feedback, via numerous phone calls, regarding the procedures posted for collecting packaging and shipping specimens and the availability of the proper supplies. The key issues that need to be addressed include: - Making the documents more clear and concise, perhaps by presenting the material in an SOP or flowchart format. - Providing better differentiation between shipping procedures using a private courier versus a commercial transporter. Recommend ations consulted when making the updates. 1.3.1. MDH- PHL will continue to use the MLS communication system for notification of sentinel laboratories. 2.1.1. Based on the feedback received throughout the exercise, the procedures and forms will be updated to include the recommendati ons from the sentinel laboratories. CDC will be consulted when making the updates. Corrective Action Description Capability Element Communications 19 Primary Responsible Agency MDH-PHL Agency POC MLS Program Planning MDH-PHL CT Start Date Completion Date May 1, September 1, May 1, September 1,

Capability 3. Properly collect, package and ship specimens from individuals that have been exposed to chemical agents while preserving the integrity of the evidence through the proper use of chain-ofcustody and evidence taping procedures. Observation Title - Clarifying the chain-of-custody and evidence preservation procedures. 2.2. The MDH chemical terrorism website was an effective way to provide the protocols to the sentinel laboratories. 3.1. Many labs do not have access to dry ice for shipping urine samples. 3.2. Many labs did not fill out the chain-ofcustody form properly. 3.3. Many labs did not fill out Recommend ations 2.2.1. MDH will continue to use the website for posting protocols and other reference materials. 3.1.1. MDH will follow up with the CDC to determine what their quality requirements are for handling urine specimens that are not frozen during transport. 3.2.1. Chainof-custody form will be redesigned for better clarity and efficient use. 3.3.1. Chainof-custody Corrective Action Description Capability Element Communications Primary Responsible Agency MDH-PHL Agency POC CT Planning MDH-PHL CT Planning MDH-PHL CT Planning MDH-PHL CT Start Date Completion Date May 1, September 1, May 1, September 1, May 1, September 1, May 1, September 1, 20

Capability 4. Test the ability of the courier network that delivers specimens to the Public Health Laboratory to handle an increased volume of samples which may result from a chemical release event. Observation Title the chain-ofcustody form properly. 3.4. There was confusion over chain-of-custody protocol, specifically with the question of whether couriers were supposed to be part of the string of custody and if they should sign the form. In addition labs were not sure who was supposed to keep the original chainof-custody form. 4.1. MDH found that many laboratories in the western part of the state rely on a single hospital courier system, which ran out of dry ice and shipping containers during the exercise. 4.2. During the exercise a snow storm hit the state which Recommend ations form will be redesigned for better clarity and efficient use. 3.4.1. MDH will contact CDC to clarify the chainof-custody procedure to better align with routine practices of sentinel laboratories and to clarify the courier s role. 4.1.1. Since many labs rely on the same dry ice supplier that can easily be overwhelmed by a surge in demand, MDH will encourage the sentinel laboratories to locate multiple sources of dry ice. 4.2.1. Depending on the extent of the weather Corrective Action Description Capability Element Primary Responsible Agency Agency POC Planning MDH-PHL CT Logistics/ Planning MDH-PHL CT Planning MDH-PHL CT Start Date Completion Date May 1, September 1, May 1, September 1, May 1, September 1, 21

Capability 5. Communicate findings from all three stages of the exercise to the sentinel laboratories through regional conference calls following the end of Stage 3, and prepare a summary report for Stage 3 for each participating sentinel lab. Observation Title kept several of the couriers from delivering specimens within the specified timeframe. 5.1. The regional hot wash teleconference s had very poor attendance from the laboratories that were involved in the exercise. 5.2. The regional hot wash provided timely observations from the laboratories. Recommend ations delay, we may have to accept that samples will be delayed. The safety of individuals deliveing specimens should always take precedence over timely delivery. 5.1.1. In the future, conference calls will be included in the exercise time table so that all of the participants will be aware of them from the beginning of the exercise. 5.2.1. Schedule hot wash teleconferences after future exercises. Corrective Action Description Capability Element Communications Primary Responsible Agency MDH-PHL Agency POC CT Planning MDH-PHL CT Start Date Completion Date May 1, September 1, May 1, September 1, 22

Capability 6. Provide a forum for attending sentinel laboratories to voice concerns and lessons learned about the procedures for collecting, packaging and shipping specimens, and about the exercise as a whole, at the MLS Regional Laboratory Conferences. Observation Title 6.1 Regional conferences effectively provided a forum for discussion about the exercise. Recommend ations 6.1.1. In future exercises continue to provide interactive presentations at the regional conferences to facilitate discussion. Corrective Action Description Capability Element Primary Responsible Agency Agency POC Planning MDH-PHL CT Start Date Completion Date May 1, September 1, 23