Section 9 - Education, Training and Exercises

Table of Contents

A. Overview 9-1

B. Related Standards 9-1

1\. The Joint Commission 9-1

2\. Department of Homeland Security, National Incident Management System
(NIMS) 9-1

3\. National Fire Protection Association Standard 1600 9-2

4\. Department of Homeland Security, Continuity of Operations Planning
(COOP) 9-2

C. Important Additional Reading 9-3

D. Philosophy 9-3

E. Development of an Education/Training Plan 9-3

F. The Role Competencies Play 9-4

1\. Organizational Priorities 9-4

2\. Target Audiences and Sample Competencies 9-4

3\. Training and Exercise Program Assessment 9-5

G. Education and Training Resources 9-5

1\. All Personnel 9-5

2\. Leaders and Key Operating Unit Managers 9-6

3\. Education and Training Programs for Patient Care Providers 9-8

4\. VHA Education and Training Program for Decontamination Teams 9-9

5\. Education and Training Programs for Emergency Program Managers 9-9

H. Exercise Programs 9-11

1\. Purpose 9-11

2\. Types of Exercises 9-12

3\. Exercise Development Process 9-13

I. Example Scenarios 9-14

1\. Flood Example 9-14

2\. VA/DoD Contingency Hospital System Example 9-15

3\. Mass Casualty Incident Example 9-16

4\. Hurricane Example 9-17

5\. External HAZMAT Plume 9-18

6\. Bombing With Prior Threat Example 9-19

7\. Earthquake Example 9-20

8\. Pandemic Influenza Example 9-22

> *Some of the following documents are on the CD-ROM only that
> accompanies this Guidebook, and all are at the CEOSH web site
> ([http://vaww.ceosh.med.va.gov](http://vaww.ceosh.med.va.gov/)):*

J. Enclosures

> 9-1. Appendix C, Health Care Management Competencies, Competency
> Framework Final Report CD
>
> 9-2 New Employee Orientation Guideline for Emergency Program Managers
> 9-27
>
> 9-3. Example VA/DoD Exercise 9-31
>
> 9-4. Example Federal/State/Local Exercise Plan CD
>
> 9-5. Example Exercise Area Diagram CD
>
> 9-6. Tabletop Exercise Template CD
>
> 9-7. Example Tabletop PowerPoint Template 9-33
>
> 9-8. Example Exercise Critique/After Action Report CD
>
> 9-9. FEMA's Guide to Emergency Exercises CD
>
> 9-10. Recommendations for a Health System Emergency Management
> Certification Program CD
>
> 9-11. Sample VA Pandemic Influenza Tabletop Exercise 9-35

Section 9 - Education, Training and Exercises

A. Overview

Like Step Five, education and training activities are on-going in
nature, based upon the organization's Emergency Operations Plan (EOP)
and Standard Operating Procedures (SOPs). Staff are trained on the
Incident Command System (ICS) to the level consistent with their role in
the organization's EOP.

The purpose of this Section is to provide guidance for regular training
to staff on their responsibilities during emergencies and disasters,
with the goal of reducing uncertainty and improving effectiveness. This
guidance applies to staff that are responsible for developing and
conducting emergency management education, training and exercises at
Veterans Health Administration Central Office (VHA CO), Veterans
Integrated Service Networks (VISNs) and VA Medical Centers (VAMCs).
These responsibilities are often shared by several offices (e.g.,
Education, Safety and Quality Management), and are accomplished through
a subgroup of the Emergency Management Committee (EMC). This information
is intended to build upon training that is currently offered, not
replace it.

B. Related Standards

1\. **The Joint Commission**.

[EC.4.16, Strategies for Managing Staff]{.underline}.

2\) Staff are trained for their assigned roles during emergencies.

2\. **Department of Homeland Security, National Incident Management
System (NIMS)**.

-   Complete concepts and competencies in an equivalent course or take
    IS-100, IS-200, and IS-700. (Established 2007, required 2007.)

-   Complete IS-800: NRP, An Introduction or equivalent. (Established
    2007, required 2007.)

-   Complete ICS-300 Training or equivalent. (Established 2008, required
    2009.)

-   Complete ICS-400 Training or equivalent. (Established 2008, required
    2009.)

-   Promote NIMS concepts and principles into the organization's
    department, business unit, and/or local jurisdiction-sponsored
    training. (Established 2007, required 2008.)

-   Conduct delivery of NIMS training in conformance with the National
    Standard Curriculum Training Development Guidance (March 2007) and
    the Five-Year NIMS Training Plan upon release October 1, 2007.
    (Established 2008, required 2009.)

-   Promote NIMS concepts and principles into all organization-related
    training and exercises. Demonstrate the use of NIMS principles and
    ICS Management structure in training and exercises. (Established
    2007, required 2008.)

3\. **National Fire Protection Association, Standard 1600**.

5.13 Training.

5.13.1 The entity shall develop and implement a training/educational
curriculum to support the program.

5.13.2 The objective of the training shall be to create awareness and
enhance the skills required to develop, implement, maintain, and execute
the program.

5.13.3 Frequency and scope of training shall be identified.

5.13.4 Personnel shall be trained in the entity\'s incident management
system.

5.13.5 Training records shall be maintained.

5.13.6 The training and education curriculum shall comply with all
applicable regulatory requirements.

4\. **Department of Homeland Security, Continuity of Operations Planning
(COOP)**. Testing, training and exercising of COOP capabilities is
essential to demonstrating and improving the ability of agencies to
execute their COOP plans. Training familiarizes contingency staff
members with the essential functions they may have to perform in an
emergency. Tests and exercises serve to validate, or identify for
subsequent correction, specific aspects of COOP plans, policies,
procedures, systems, and facilities used in response to an emergency
situation. Periodic testing also ensures that equipment and procedures
are maintained in a constant state of readiness. All agencies shall plan
and conduct tests and training to demonstrate viability and
interoperability of COOP plans. COOP test, training, and exercise plans
should provide for:

a\. Individual and team training of agency COOP contingency staffs and
emergency personnel to ensure currency of knowledge and integration of
skills necessary to implement COOP plans and carry out essential
functions. Team training should be conducted at least annually for COOP
contingency staffs on their respective COOP responsibilities.

b\. Internal agency testing and exercising of COOP plans and procedures
to ensure the ability to perform essential functions and operate from
designated alternate facilities. This testing and exercising should
occur at least annually.

c\. Testing of alert and notification procedures and systems for any
type of emergency at least quarterly.

d\. Refresher orientation for COOP contingency staff arriving at an
alternate operating facility. The orientation should cover the support
and services available at the facility, including communications and
information systems for exchanging information if the normal operating
facility is still functioning; and administrative matters, including
supervision, security, and personnel policies.

e\. Joint agency exercising of COOP plans, where applicable and
feasible.

C. Important Additional Reading

Emergency Management Principles and Practices for Health Care Systems:

-   Unit One: The Emergency Management Program (Pages 1-32 to 1-75)

-   Unit Four: Instruction, System Evaluation, and Organizational
    Learning (Pages 4-1 to 4-50)

-   Unit Five: Appendices (Health System EM Competency Framework) (Pages
    5-73 to 5-133, and 2007 Update) - see
    [www.va.gov/emshg](http://www.va.gov/emshg)

-   Awareness-level course, complete with instructional outline, slides
    and handouts. Available at:
    [www.va.gov/emshg](http://www.va.gov/emshg)

D. Philosophy

VHA currently does not mandate that employees receive education and
training in emergency management beyond that required by Joint
Commission (EC.4.16). In some cases other requirements exist, such as
for members of Decontamination Teams who are subject to Occupational
Safety and Health Administration (OSHA) training requirements (First
Receiver), and VHA officials for Continuity of Operations Planning
(COOP) Guidance, Federal Preparedness Circular No. 65. Regardless,
employees who are assigned roles and responsibilities in the Emergency
Operations Plan (EOP) must be given the opportunity to become familiar
with what is expected of them. This can be accomplished through a
comprehensive preparedness program that includes standards development,
education, training, exercises and corrective action. Facility
preparedness for the emergency situations should be considered a
continuous cycle of education, exercises, corrective actions and program
improvement.

E. Development of an Education/Training Plan

The Emergency Management Committee (EMC) sets policy for the VAMC or
VISN emergency management program, including setting standards for staff
education and training. Examples of important issues that should be
considered include:

-   Identification of training needs for each job group, including
    appropriate standards and accepted practices.

-   Establishment of basic training requirements for all personnel, the
    Incident Management Team and specialized activities (such as COOP,
    DEMPS, decontamination, patient reception, bomb threat and fire
    response).

-   Identification of an annual schedule of training and exercise
    activities needed to support the Emergency Operations Plan.

-   Identification of training responsibilities.

-   The funding and staffing of the preparedness-training program.

F. The Role Competencies Play

Training, education and exercises must meet the unique needs of the
facility and the community in which it resides. The activities must also
be tailored to develop the knowledge, skills and abilities of the
various target audiences. The term "competency" as used here refers to a
specific knowledge element, skill, and/or ability that is objective and
measurable (i.e., demonstrable) on the job. It is required for effective
performance within the context of a job's responsibilities, and leads to
achieving the objectives of the organization.

1\. *Organizational Priorities*. The overall objectives that guide the
organization's response to and recovery from emergencies include:

-   Safety of patients, visitors and staff.

-   Continuity of patient care and essential business functions.

-   Surge capacity and capability.

-   Protection of records, the environment and property.

Consequently, the organizational competencies or capabilities include
maintaining the following:

-   An information management and communications system that enables
    linkage with internal and external authorities.

-   A current Emergency Operations Plan (EOP) that incorporates the
    Incident Command System (ICS) and addresses the following six
    critical areas: emergency communications; resource management;
    safety and security; staff roles and responsibilities; utilities
    management; and, patient and clinical support activities during
    emergencies.

-   A decontamination system and security procedure to prevent facility
    contamination due to natural, technological or man-caused hazards.

-   Redundant sources of essential utilities and resources needed to
    maintain facility operations.

-   Clinical and support staff, procedures, supplies and equipment
    necessary to care for the current patient population and others who
    may require treatment.

2\. *Target Audiences and Sample Competencies*. To support development
of VHA's Emergency Management Academy, the various target audiences were
organized into what is referred to as "job groups" (see below), and
sample emergency response and recovery competencies were then
identified. The complete list of job groups and competencies is
Enclosure 9-10 to this Section.

-   All Personnel (core competencies)

-   Healthcare System Leaders

-   Patient Care Providers

-   Clinical Support

-   Facilities Engineering

-   Police and Security

-   Emergency Program Managers

3\. *Training and Exercise Program Assessment*. The following questions
can be used to assess the viability of the current training and exercise
program:

> \_\_Does an organized awareness level training program exist for all
> employees?
>
> \_\_Does an organized training program for all involved response
> personnel exist?
>
> \_\_Has one individual or team been designated to coordinate this
> training?
>
> \_\_Does the training include roles and responsibilities for each of
> the four job groups listed above?
>
> \_\_Have training standards or criteria been established for the
> positions in the VAMC/VISN ICS organization?
>
> \_\_Are instructors appropriately trained and certified (if required)?
>
> \_\_Does the training program provide for refresher courses or some
> other method to ensure that personnel remain up-to-date in their level
> of expertise?
>
> \_\_Have internal and external resources and organizations available
> to provide training been identified?
>
> \_\_Is there a record-keeping system in place for the documentation of
> past training events?
>
> \_\_Are exercises conducted in accordance with The Joint Commission
> (TJC) and agency requirements?
>
> \_\_Are exercise evaluations and critiques forwarded to the Emergency
> Management Committee for review, approval and actions?
>
> \_\_Are follow-up actions and program improvement steps documented?

G. Education and Training Resources

1\. *All Personnel*. VHA's Employee Education System (EES) supports the
development and distribution of emergency management education and
training programs. Recent EES projects include:

-   [Emergency Management Principles and Practices for Health Care
    Systems.]{.underline} (Glossary, Competency Framework and
    Curriculum). The texts were developed by the Institute for Crisis,
    Disaster and Risk Management at The George Washington University,
    under contract to the VHA. The contract called for the
    identification and validation of emergency response and recovery
    competencies for four job groups within healthcare organizations and
    the development of a curriculum that addressed emergency management
    program concepts and practices, incident management systems and
    processes, and organizational learning strategies. These are
    available at: <http://www1.va.gov/emshg/page.cfm?pg=122>

-   On-line courses via VA Learning Management System (VA LMS)
    (<https://www.lms.va.gov/>).

> Introduction to Emergency Management for Health Care Systems
>
> Developing an Emergency Management Program

-   Satellite programs via VA Knowledge Network. VAMC and VISN Education
    Coordinators receive information from EES about VAKN programs,
    useful web-based training programs and other resources. The EES
    catalog can be accessed at
    <http://vaww.sites.lrn.va.gov/vacatalog/>.

2\. *Leaders and Key Operating Unit Managers*. Several web-based
independent study courses are available to provide an orientation to the
National Incident Management System (NIMS), as well as the National
Response Plan (NRP)/National Response Framework (NRF). The Deputy Under
Secretary for Health for Operations and Management (DUSHOM) in a January
17, 2007, Memorandum concerning NIMS stated: "It should also be noted
that NIMS compliance elements include the completion of specific
training. While no specific training requirements are mandated for VHA
at this time, it is [strongly recommended]{.underline} that individuals
assigned to the VHA positions listed in Attachment B begin taking the
required courses with a goal of completing the NIMS requirements before
the end of FY 2007." A link to this web-based training is available
through FEMA's independent study program at the following web address:
<http://www.training.fema.gov/EMIWeb/IS/crslist.asp>. Those positions
for whom the NIMS-related training is recommended include:

**NIMS, NRP/NRF and ICS Training Requirements**

**[ICS Roles]{.underline} [NIMS/NRP/NRF/ICS Courses]{.underline}
[Positions]{.underline}**

**Agency Executive** [IS-700 and IS-800]{.underline} VHA CO - Chief
Officers, DUSHOM, USH

VISN - VISN Directors

VA Medical Centers - VAMC Directors

**Command and** [IS-700 and IS-800]{.underline}

**General Staff** [ICS-100 and ICS-200 (FY 2008)]{.underline}

(VHA CO, VISN, [ICS-300 and ICS-400 (FY 2009)]{.underline}

VAMC)

**VHA CO**

*Command Staff:*

Incident Mgmt. Team Commander Director, Network Support or Senior HSS

Safety Officer Director, Safety and Technical Programs

Public Information Officer Director, Public Affairs

Liaison Officer Director, Emergency Management

*General Staff:*

Operations Section Chief Senior HSS or EMSHG Staff

Plans Section Chief Senior HSS or EMSHG Staff

Logistics Section Chief Senior HSS or EMSHG Staff

Finance/Admin Section Chief Senior HSS or EMSHG Staff

**VISN Offices**

*Command Staff:*

Incident Mgmt. Team Commander Deputy Network Director

Safety Officer VISN Safety Officer

Public Information Officer VISN Public Affairs

Liaison Officer VISN EM or EMSHG AEM

*General Staff:*

Operations Section Chief Chief Operating Officer

Plans Section Chief VISN EM or EMSHG AEM

Logistics Section Chief Chief Logistics Officer

Finance/Admin Section Chief Chief Fiscal Officer

**VA Facilities**

*Command Staff:*

Incident Mgmt. Team Commander Associate Director or Chief of Staff

Safety Officer Safety Officer

Public Information Officer Public Affairs Officer

Liaison Officer Emergency Program Coordinator

*General Staff:*

Operations Section

Health and Medical Group Senior Clinical Staff

Business Continuity Group Senior Administrative Staff or Chief, IT

Equip, Plant & Utilities Group Chief, Engineering/Facility Management

Safety & Security Group Chief, Police/Security or Safety Officer

Plans Section Chief Emergency Program Coordinator

Logistics Section Chief Chief, AM&M

Finance/Admin Section Chief Chief, Fiscal or Business Operations

It is recommended that government, private-sector, and non-governmental
organization individuals and teams who are charged with working together
in a network to manage resources during domestic incidents review the
following course, to enable incident managers, logistics managers, and
other State, tribal or local officials to plan for, manage and implement
resource management systems for times of crisis and disaster.

**IS-703 - NIMS Resource Management**. This interactive computer-based
course provides the principles, tools, processes and systems used in the
National Incident Management System (NIMS) that incident managers need
for timely and effective resource management during an incident. Primary
tasks addressed in this course are establishing systems for describing,
inventorying, requesting and tracking resources; activating these
systems prior to and during an incident; dispatching resources prior to
and during an incident; and deactivating or recalling resources during
or after incidents. This course should take approximately 3 to 4 hours
to complete. To obtain the IS-703 course materials or take the course
online go to:
<http://training.fema.gov/emiweb/is/is703.asp>[.]{.underline}

At the conclusion of the course, participants should understand how
resources, personnel, teams, facilities, equipment and supplies, are
managed through this NIMS system by advance planning and:

> • Resource identification and ordering.
>
> • Categorizing resources.
>
> • Use of agreements.
>
> • Acquisition management.
>
> • Management information systems.
>
> • Protocols for ordering, mobilization and dispatching.

The course may be taken online, or course materials may be downloaded
and used in a group or classroom setting. Answer sheets may be obtained
by calling the EMI Independent Study Office at (301) 447-1256 or ordered
online at: <http://www.training.fema.gov/EMIWeb/IS/ansreq.asp>

3\. *Education and Training Programs for Patient Care Providers*.

a\. Medical Response to Weapons of Mass Destruction (WMD). In accordance
with Section 3 of the Department of Veterans Affairs (VA) Emergency
Preparedness Act of 2002, also known as Public Law 107-287, VA was
directed to develop and disseminate to VA healthcare professionals a
series of comprehensive educational and training modules on medical
response to a potential attack with weapons of mass destruction (WMD).
As part of this effort, the Employee Education System (EES) has produced
a series of modules intended to provide all VA and DoD healthcare
providers, facility leadership and network leadership with a
comprehensive resource in case of an actual incident involving weapons
of mass destruction \[chemical, biological, radiological, nuclear and
explosives (CBRNE)\].

b\. Veterans Health Initiative (VHI) (<http://www.va.gov/vhi>). This
Initiative, part of the Office of Public Health and Environmental
Hazards, is a comprehensive program to recognize the connection between
certain health effects and military service, to allow military medical
history to be better documented, and to prepare healthcare providers to
better serve their veteran patients. The independent study courses below
have been developed to deliver important education and information in
the specified areas.

c\. Other Training Resources for Care Providers. Department of Defense
Uniformed Services University of Health Sciences
([http://www.cdham.org](http://www.cdham.org/)). The Uniformed Services
University of Health Sciences is the Department of Defense's Medical
School located on the campus of the National Naval Medical Center in
Bethesda, MD. Currently, its WMD education and training program includes
the Graduate School of Nursing, three Medical Readiness Centers, the
National Capital Area Medical Simulation Center, a Computer Aided
Virtual Environment and Military and Emergency Medicine Department
(MEM). A subordinate element of the MEM is the Center for Disaster and
Humanitarian Assistance Medicine (CDHAM), whose mission includes
providing training and education to civilian and military personnel
worldwide; to conduct studies leading to evidence-based policies,
procedures and educational content; and, to provide consultative and
direct assistance to organizations involved in disaster
response/humanitarian assistance.

-   American Medical Association National Disaster Curriculum. The Basic
    Disaster Life Support (BDLS) Provider Manual developed by the
    National Disaster Life Support Education Consortium in conjunction
    with American Medical Association (AMA). The BDSL concept utilizes
    the idea of a single basic course followed by more subject-specific
    learning units; however, the members noted that the implementation
    of the BDSL concepts could be improved upon, particularly in the
    area of mental health issues and the documentation of supporting
    evidence and accompanying references.

-   The Center for Disease Control and Prevention has numerous training
    resources for public health specialists and healthcare providers.
    \[See the Centers for Disease Control(CDC) Emergency Preparedness
    Training Website for details <http://www.bt.cdc.gov/training/#ph>.\]

-   The Department of Defense has a website dedicated to training
    modules, many of which are designed specifically for healthcare
    providers. (See the National Homeland Security Knowledgebase website
    for details <http://www.twotigersonline.com/resources.html>.)

4\. *VHA Education and Training Program for Decontamination Teams*. VHA
Mass Casualty Decontamination Program
(<http://vaww1.va.gov/environagents/docs/Directive2003-045.pdf>). This
program provides policy, procedures, training and funding for supplies
and equipment for VA Medical Centers to develop and implement
decontamination capability based upon local and community needs. Focus
is placed on protection of the Medical Center, staff and patients in the
event of an off-site incident. The training addresses provision of
emergency care for casualties arriving at the facility following an
emergency. The training is provided by two teams located at Houston, New
York/New Jersey and Little Rock, AR. This train-the-trainer format
offers both awareness and operations level courses based on NFPA 472,
NFPA 473 and the Domestic Preparedness Program. This program meets all
the requirements outlined in the OSHA document: OSHA Best Practices for
Hospital Based First Receivers of Victims from Mass Casualty Incidents
Involving the Release of Hazardous Substances, December 2004, and
recognized by FEMA
(<http://www.osha.gov/dts/osta/bestpractices/firstreceivers_hospital.html>).
The Decontamination Program training materials are provided on CD-ROM,
and include 18 modules as follows:

a\. Awareness Level Training Modules:

-   Introduction and Overview

-   Regulations and Hazard Recognition

-   Toxicology

-   Personal Protective Equipment (PPE)

b\. Operations Level Training Modules:

-   Emergency Response Plan Implementation

-   Risk Assessment and Hospital Planning

-   Bioterrorism

-   Chemical Warfare Agents

-   Industrial Chemical Emergencies

-   Radiological Emergencies

-   Toxicology

-   Personal Protective Equipment (PPE)

-   Medical Cache

-   Medical Triage

-   Decontamination Area and Equipment

-   PPE - Donning/Doffing

-   Effective Presentations

-   Train-the-Trainer

5\. *Education and Training Programs for Emergency Program Managers*.

a\. FEMA Emergency Management Training Courses
(<http://www.fema.gov/about/training/index.shtm>). The FEMA website is
continuously updated, and provides an excellent resource for ongoing
educational materials. An example is the Professional Development series
that includes seven Emergency Management Institute independent study
courses that provide a well-rounded set of fundamentals for those in the
emergency management profession. The courses are self-paced independent
studies, and each takes between 8 and 15 hours to complete.

> **IS-230** - Principles of Emergency Management. This course is
> designed to provide a basic framework of understanding of emergency
> management.
>
> **IS-235** - Emergency Planning. This course is designed to prepare
> planners to use the standard terminology and concepts of a properly
> structured Emergency Operations Plan.
>
> **IS-242** - Effective Communication. This course is designed to
> improve your communication skills.
>
> **IS-241** - Decision Making and Problem Solving. This course is
> designed to improve your decision-making skills.
>
> **IS-240** - Leadership and Influence. This course is designed to
> improve your leadership and influence skills.
>
> **IS-244** - Developing and Managing Volunteers. This course is for
> emergency managers and related professionals working with all types of
> volunteers and coordinating with voluntary agencies. The course
> provides procedures and tools for building and working with voluntary
> organizations.
>
> **IS-139** - Exercise Design. This course is designed to develop skill
> in designing effective exercises.

b\. Other Important Independent Study Courses:

> **IS-208** - State Disaster Management. This independent study course
> provides fundamental information on the disaster assistance process
> and disaster assistance programs. Individuals who serve as State
> Coordinating Offices are encouraged to attend the FEMA State
> Coordinating Officer Course (E208).
>
> **IS-244** - Developing and Managing Volunteers. This course is for
> emergency managers and related professionals working with all types of
> volunteers and coordinating with voluntary agencies. The course
> provides procedures and tools for building and working with voluntary
> organizations.
>
> **IS-275** - The Emergency Operations Center (EOC)'s Role in Community
> Preparedness, Response and Recovery Activities. This course will
> provide an understanding of the vital role an EOC plays in the overall
> community's preparedness, response and recovery activities. It is a
> prerequisite for G-275, Emergency Operations Center (EOC) Management
> and Operations.
>
> **IS-288** - The Role of Voluntary Agencies in Emergency Management.
> This course provides a basic understanding of the history, roles and
> services of disaster relief voluntary agencies in providing disaster
> assistance. It is appropriate for both the general public and those
> involved in emergency management operations.
>
> **IS-301** - Radiological Emergency Response. This course is a
> prerequisite to the resident course, S301, Radiological Emergency
> Response Operations (RERO). Its purpose is to provide a learning
> experience in which participants demonstrate a comprehensive
> understanding of radiological protection and response principles,
> guidelines and regulations to prepare them for the operations course
> (RERO). Only those approved to attend the RERO course should take this
> independent study course.
>
> **IS-317** - Introduction to Community Emergency Response Teams. This
> course serves as an introduction to CERT for those wanting to complete
> training or as a refresher for current team members.
>
> **IS-324** - Community Hurricane Preparedness. This course is designed
> to provide those involved in the decision-making process for
> hurricanes with basic information about how hurricanes form, the
> hazards posed by hurricanes, how the National Weather Service
> forecasts future hurricane behavior and what tools and principles can
> help emergency managers prepare their communities.
>
> **IS-346** - Orientation to Hazardous Materials for Medical Personnel.
> This course is designed to prepare hospital personnel to analyze
> hazardous materials situations, take the necessary steps to assure
> medical provider safety and identify appropriate resources for
> decontamination and medical care. However, additional training is
> required in order to diagnose and treat patients who have been
> involved in hazardous materials incidents. This course alone does not
> fulfill all of OSHA\'s requirements for hazardous materials training
> at the awareness level.
>
> **IS-393** - Introduction to Mitigation. This course provides an
> introduction to mitigation for those who are new to emergency
> management and/or mitigation. It is also a prerequisite for a
> non-resident Applied Practices Series course called Mitigation for
> Emergency Managers.

H. Exercise Programs

In 2008, VHA is planning to conduct the first of a series of annual
exercises that be designed to evaluate VHA Central Office, VISN and VA
Medical Center emergency operations plans and incident-specific
procedures. The focus of the 2008 exercise, to be conducted in mid-June
will be an influenza pandemic. Additional information on this annual
exercise and exercise development guidance will be available at:
[www.va.gov/emshg](http://www.va.gov/emshg)

An emergency management exercise is an activity designed to promote
emergency preparedness; test or evaluate emergency operations plans,
procedures or facilities; train personnel in emergency management
duties; and, demonstrate operational capability. Exercises consist of
the performance of duties, tasks or operations very similar to the way
they would be performed in a real emergency.

1\. *Purpose*. The fundamental purpose of an exercise program is to
improve operational readiness. Implementation of an effective exercise
will help facilities:

-   Reveal planning weaknesses.

-   Reveal resource gaps.

-   Improve coordination.

-   Clarify roles and responsibilities.

-   Motivate officials to support the emergency program.

-   Develop proficiency and confidence of participants.

-   Test plans and systems in "live" situations.

-   Foster cooperation among government agencies and private sector
    resources.

Through post-exercise assessments, participants in the exercise are able
to identify how things went, and develop a list of recommendations to
the Emergency Management Committee for corrective action. This ensures
ongoing program improvement and readiness.

2\. *Types of Exercises*. Exercises can be divided into five basic
categories:

a\. [Orientation Seminars]{.underline}. Orientation Seminars are
characterized by low stress, little attention to real time, lower level
of preparatory effort, and only rough attempts to simulate reality. The
focus is on training and familiarization with roles, procedures,
responsibilities and personalities in the jurisdiction's emergency
management system. They are usually informal, in a conference room
environment, and designed to elicit constructive discussion by the
participants as they attempt to examine the jurisdiction\'s emergency
management policy, and then resolve problems based on existing emergency
operations plans. The general purpose is for participants to evaluate
plans and procedures and to resolve questions of coordination and
assignment of responsibilities in a non-threatening format and under
minimum stress.

b\. [Drills]{.underline}. Drills are characterized by activities that
test, develop or maintain skills in a single emergency response
procedure. The focus is limited, and drills are considered as part of
necessary ongoing training. The combination of orientation seminars and
drills are important preparatory steps for the next three exercise
categories: tabletops, functional exercises and full-scale exercises.

c\. [Tabletop Exercises]{.underline}. Tabletop Exercises simulate
emergency situations; and are intended to evaluate plans and procedures,
and to resolve questions of coordination and assignments of
responsibility. Tabletop exercises are not concerned with time
pressures, stress or actual simulation of specific events.

d\. [Functional Exercises]{.underline}. Functional Exercises are
intended to test or evaluate the capability of an individual function,
or complex activity with a function. It is only applicable where the
activity or function can be effectively evaluated in isolation from
other emergency management activity. An example would be an exercise of
the Incident Command System. In this example you could test and evaluate
the centralized emergency operations capability and timely response of
the Incident Management Team under a stress environment.

e\. [Full-Scale Exercise]{.underline}. A full-scale exercise is intended
to evaluate the overall operational capability of the emergency
management program in an interactive manner over a substantial period of
time. It involves the testing of a major portion of the basic elements
existing within emergency operations, plans and organizations in a
stressful environment.

3\. *Exercise Development Process*. An exercise development program is a
commitment to incorporate progressively more challenging exercises over
a period of time. This form of long-range planning for exercises helps
bolster the essential parts of an emergency management program. There
are five general steps in developing an emergency management exercise
program. Each is described below.

a\. [Establishing the Base]{.underline}. Preparing an exercise involves
several tasks. To establish a firm and consistent base for your
exercise, you will need to:

-   Review the current emergency plan.

-   Conduct a needs assessment.

-   Assess your capability to conduct an exercise.

-   Define the exercise scope.

-   Select an exercise type.

-   Address costs and liabilities.

-   Develop a statement of purpose.

-   Announce the exercise.

b\. [Exercise Development]{.underline}. Developing an exercise involves
the following steps:

-   Identify Resources.

-   Plan the Exercise.

-   Develop Simulation Materials.

-   Prepare Facilities; Create Displays and Materials; and Consider
    Exercise Logistics.

-   Identify, Select and Train Staff.

c\. [Conducting the Exercise]{.underline}. Each type of exercise can be
conducted in a variety of ways; the method chosen should support the
objectives established for the event. Please refer to the FEMA Guide to
Emergency Management Exercises for more information
(<http://training.fema.gov/EMIWeb/IS/is139.asp>).

d\. [Exercise Evaluation and Critique]{.underline}. A realistic exercise
provides the best opportunity for an organization to evaluate its
emergency operations plan. The extent and depth of the evaluation to be
undertaken is determined by the type of exercise and the objectives for
the training event. See the Enclosures folder on the CD-ROM for template
evaluation tools.

e\. [Exercise Follow-up]{.underline}. Just as conducting an exercise
without doing an After-Action Report (AAR) makes the exercise
incomplete, the recommendations in an AAR without follow-up and
corrective action will keep the organization from getting the full
benefit of the exercise.

A Corrective Action Program (CAP) is a process that follows an exercise
or actual occurrence to identify program shortfalls and necessary
corrective actions to address those shortfalls. The CAP begins following
the AAR/discussion/critique of the incident or exercise where
deficiencies are noted that require improvement. These can be
categorized as follows:

-   Plan or standard operating procedures (SOP) revisions.

-   Training.

-   Equipment additions or modifications and facilities.

1\) Components. There are eight components in the Corrective Action
Program, as follows:

-   Develop a problem statement that states the problem and identifies
    its impact.

-   Review the past history of corrective action issues from previous
    evaluations and identify possible solutions to the problem.

-   Select a corrective action strategy and prioritize the actions to be
    taken.

-   Provide authority and resources to the individual assigned to
    implementation so that the designated change can be accomplished.

-   Identify the resources required to implement the strategy.

-   Check on the progress of completing the corrective action.

-   Forward problems that need to be resolved by higher authorities to
    the level of authority that can resolve the problem.

-   Test the solution through exercising once the problem is solved.

2\) Task Groups. A task group is assigned to each identified area of
noted deficiency to develop the necessary actions for improvement, and a
time schedule for development of the necessary corrective action is
established. The task group should do the following:

-   Develop options for appropriate corrective action.

-   Make recommendations for a preferred option.

-   Develop an implementation plan, which should include training.

-   Ensure that during the next exercise the corrective action be
    evaluated to determine if the corrective actions have been
    successful.

I. Example Scenarios

1\. *Flood Example*.

a\. Background - 555 bed community hospital with adjacent offices for
ambulatory services. This hospital serves as the major healthcare
facility for the county. It sits on the same level as the rest of the
city structures - several feet above the level of the area's lakes and
river running approximately one mile away through the city's main
commercial area. Flooding of this river is a rare event.

b\. Initial Situation - During March and April, rainfall has been
unusually heavy. The river has continued to rise. City engineers have
stated that it's unlikely the river will crest over the banks, but it's
possible if the rain doesn't stop. Weather forecast for the next five
days calls for continued rain, but the rain is expected to be lighter.

c\. Initial Situation Questions/Issues Needing Resolution -

1\) Should the hospital take any action at this time? If so, what?

2\) What are the mental health issues?

3\) Are there any specific actions the hospital should plan for/request
from the city as precautionary?

d\. Continuing Situation - The rain continues, and the weather service
was inaccurate. The rain has been heavy. Weather forecast now states
that the rain should ease, and end in three-four days. City engineers
state that the river is likely to overflow the banks within the next
eight hours. They expect the river to crest in three days. The National
Guard has been called to add sand bags, but the outlook of containment
is bleak.

e\. Continued Situation Questions and New Issues -

1)  Decide to shelter-in-place or evacuate, and develop a plan to
    execute.

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1)  Regardless of your decision, project staff and supplies shortfalls
    that would likely occur if you stay in place, and develop courses of
    actions.

2)  Plan for loss of utilities.

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1)  How does the hospital coordinate its planning with the city?

2)  Decide if you will shelter-in-place or evacuate. Are there any other
    options?

3)  Develop a plan of action to support the execution of your decision.

4)  Public affairs issues.

2\. *VA/DoD Contingency Hospital System Example*.

a\. Background - 555-bed general medical/surgical facility - affiliated
with medical, dental and nursing schools - provides tertiary support to
other VAMCs in area. Military Reserve Component member for the hospital
employees: 7% MDs; 10% RNs and LPNs; 5% nursing assistants; 25%
respiratory technicians; 5% pharmacists; 8% engineering; 4% various
administrative positions; 2% nursing assistants; 2% DDSs/dental
assistants; and, 2% laboratory technicians/phlebotomists.

b\. Initial Situation - The US, along with NATO forces, has just
attacked Iraq. The enemy forces have threatened to use nuclear,
biological and chemical agents both overseas and within the United
States. DoD is rapidly calling up the medical personnel in the Reserve
Components. CDC has determined that a voluntary smallpox "response team"
should be established at each hospital having in excess of 100 beds. The
original (dried calf lymph) smallpox Vaccine is available for these team
members.

c\. Initial Questions and Issues Needing Resolution -

1)  Impact of loss of staff to DoD call-up.

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1)  Security of facility.

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1)  Activation of VA/DoD Contingency Plan.

2)  Training of staff to treat patients exposed to nuclear, biological
    and chemical agents.

3)  Establishing smallpox response team, and instituting vaccination
    program.

4)  Public affairs issues.

5)  What are the mental health issues?

d\. Information About the Continuing Situation - DoD call-ups affect
mainly nursing and respiratory therapy. The smallpox response team has
been established and vaccinated. The FBI states that terrorist cells
within the US might use a chemical or biological agent. Iraq is losing
the war and launches a massive counterattack with nerve agent (an
organophosphate). Terrorists' attacks are occurring across the US. The
VAMC is expecting patients - 10 post-surgical traumas, 5 psychiatric and
12 soldiers exposed to nerve agent and still requiring atropine to
control symptoms. DoD tells VA to expect more casualties.

e\. Continued Situation Questions and New Issues -

1)  VAMC staffing for an extended period.

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1)  Security of facility.

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1)  Possible chemical and biological threat.

2)  Services for the DoD patients.

3)  Summary - Staffing was adequate to provided necessary care for DoD
    and veteran patients. Several bomb threats were received, but all
    were hoaxes. The long-term effects of (possible) exposure to
    chemical agents remain an ongoing problem.

3\. *Mass Casualty Incident Example*.

a\. Background - 415-bed hospital providing medical, surgical,
psychiatric and nursing home care to patients in a rural area.

b\. Initial Situation - Three miles from the hospital on Friday at 9:30
p.m., two school buses returning from an out-of-town activity collide
with a cattle truck. The weather is foggy. A local farmer calls 911, and
local law enforcement and fire rescue quickly respond. One bus driver
and two adult chaperones are dead. The other bus driver, adult
chaperones and truck driver are unconscious. An unknown number of
children are injured and dead. The ambulances and local citizens begin
transporting victims to the county hospital, which quickly becomes
overwhelmed. The VA hospital is requested to assist. In the neighboring
town, the children's parents are unaware of the accident and are
anxiously waiting to meet the students at approximately 10:15pm.

c\. Initial Situation Questions and Issues Needing Resolution -

1)  Activation of the hospital's emergency plan.

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1)  Staff and resources to care for the victims.

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1)  Transportation of victims.

2)  Interface with officials from local emergency services and county
    hospital.

3)  What are the public affairs issues?

4)  What are the mental health issues?

d\. Information About the Continuing Situation - Conflict develops
between the ambulance service and the hospital. The hospital is being
overwhelmed with patients, and is not being notified if/when more
patients will arrive. Radio and newspaper staff have arrived and want
information. The hospital's Public Affairs Officer cannot be located.
Recall of hospital staff is not adequate to meet the demand. The
victims' parents are frantically trying to locate their children.
Individuals from neighboring towns arrive at the hospital offering to
assist in the medical care. There is conflicting information concerning
the actual number of children involved. Due to the large number of dead,
a temporary morgue must be established. Supplies of intravenous fluids,
sterile 4X4 gauze and povidone iodine solution are critically low.

e\. Continued Situation Questions and New Issues -

1)  Use of Incident Command System.

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1)  Resolution of conflict with the ambulance service.

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1)  Public affairs issues.

2)  Establishment of temporary morgue.

3)  Lack of hospital staff and medical supply problems.

4)  Convergence of volunteers.

f\. Summary - The hospital provided care for one adult and 41 children.
Fourteen victims eventually died as a result of this accident. Negative
media interactions were aired nationally. Class action litigation is
pending.

4\. *Hurricane Example*.

a\. Background - Hospital with a rehabilitation unit is located on a
low-lying area of the coast.

b\. Initial Situation - The Chief of Staff (COS) is out of the country,
and is not expected back for eight days. The Chief of Medicine Service
has been serving as the Acting COS, but this has caused discord among a
few physicians who also wanted to serve as Acting COS. Engineering
Service just reported that the hospital's emergency power generator did
not function during a test. In addressing budgetary constraints, several
vacancies in Medical Administration, Environmental Management and
Acquisition and Materiel Management Services have remained open for the
past few months. The National Hurricane Center has been tracking a Class
II hurricane that is steadily moving toward this hospital. It is
expected to reach landfall in 28 hours. It is now 2:00pm on the last
Friday in August.

c\. Initial Situation Questions and Issues Needing Resolution -

1)  Continuity of patient care.

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1)  Decision concerning hospital evacuation.

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1)  Personnel issues.

2)  What are the public affairs issues?

3)  What are the mental health issues?

d\. Information About the Continuing Situation - The hurricane has been
downgraded to Level I, and is expected to reach landfall in four hours.
Hurricane experts disagree on the potential for a significant storm
surge. Heavy rainfall has caused some flooding in areas. The hospital
has not experienced any significant problems with flooding, but some
roof leaks have been reported by Nursing Service. The Director has
received numerous calls from patients affected by flooding. One patient
scheduled for Hemodialysis has not been able to leave his
flood-surrounded home. The Chief of Surgery Service has not supported
decisions made by the Chief of Medicine. The Associate Chief Nurse and
Chief Engineer have frequently voiced their support for the Chief
Surgeon's views. Three Nursing Service employees have experienced
diarrhea, which they feel may be related to tuna salad sandwiches
provided to patients and staff by an outside catering service.
Engineering Service reports that the main emergency power generator is
still inoperative. Two 10K generators have been borrowed from a local
National Guard Armory. The Carpenter Shop Foreman has stated that he
does need more 4x8 sheets of plywood. During the last two hours, Medical
Administration has reported that ten homeless individuals claiming to be
veterans have requested shelter at the hospital. Some hospital employees
have requested leave in order to be with their families. A few
confrontations regarding the leave requests have occurred between
managers and staff.

e\. Continued Situation Questions and New Issues -

1)  Continuity of patient care.

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1)  Decision concerning hospital evacuation.

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1)  Personnel issues.

f\. Summary - Patients were not evacuated from the hospital. One ward
was closed due to the roof leaks. The facility sustained minor damage.
The Chief of Surgery has submitted his resignation. Only two employees
were charged AWOL (absent without leave) for leaving the hospital.
However, a grievance has been filed since some employees were allowed to
use annual leave. Twenty-eight employees from other hospitals arrived to
support the affected hospital. The diarrhea outbreak affected numerous
patients and staff, but no long-term negative effects are expected. One
of the homeless patients was a narcotic addict and forced his way into
the Pharmacy. One Pharmacy Technician, who sustained head injuries
trying to thwart the robbery, has asked for Workman's Compensation.
Another homeless individual was the source of a pediculosis (lice)
outbreak on one ward. The local veteran's service organizations have
expressed displeasure over the "lack of concern for its patients."

5\. *External HAZMAT Plume*.

a\. Background - This 167-bed hospital provides primary and secondary
care to patients. It is located in an area that serves approximately
60,000 patients. Agriculture, a community college and small
manufacturing plants are located in the area. The Emergency Program
Coordinator is also the Safety Manager at this facility.

b\. Initial Situation - It is 10:15am on Tuesday, a beautiful spring
morning. Today is Volunteer Appreciation Day at this hospital. The
charcoal grills have been started, and approximately 60 volunteers have
arrived for a cookout with the hospital's patients and staff. Two miles
west of the hospital a train derails. Local EMS responds but immediately
retreats due to noxious fumes. Two tankers carrying ammonia have
ruptured. There is a four MPH wind from the southwest. The hospital
census is 90%.

c\. Initial Situation Questions and Issues Needing Resolution -

1)  Potential impact to hospital.

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1)  Protection of patients, visitors and staff.

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1)  Continuity of patient care.

2)  Role of hospital in HAZMAT response.

3)  Your role as the Emergency Manager.

4)  What are the public affairs issues?

5)  What are the mental health issues?

d\. Information About the Continuing Situation - The local fire chief
served as incident commander. Individuals living/working within the
projected plume path were ordered to evacuate at once. The community
school and shopping mall located on the southeast side of the city was
the evacuation shelter area for anyone unable or unwilling to move
farther away from the incident. Forty hospital inpatients were bused to
the shelter area. Five volunteers, one Medical Administration employee
and three nurses supervised these evacuated patients. The remaining
fifty-five volunteers left the hospital in their private automobiles.
Three inpatients asked to be discharged immediately. Surgical procedures
were ended. Patients were asked to remain in their rooms, and a census
was conducted. A forty-year-old inpatient being evaluated for
hypertension cannot be located. Engineering and Safety Services met and
suggested that all cracks around doors and windows be sealed with tape,
and the air-conditioning unit be stopped. All patients who had reported
for outpatient clinic visits were allowed to either leave or remain
inside the hospital. All visitors were encouraged to leave. If a visitor
could or would not leave, they were allowed to stay in the cafeteria
area. The EMS Director contacted the hospital Director and stated that
she had no information concerning the number of victims. The local
community hospital, located near the school, called and asked the
hospital to assist with the overflow of victims arriving at their
Emergency Room.

e\. Continued Situation Questions and New Issues -

1)  Interface with the local officials.

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1)  Continuation of patient care.

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1)  Protection of patients, visitors and staff.

2)  Your role.

f\. Summary - The ammonia leakage was finally controlled. Although the
hospital did lie in the plume pathway, only minor odors were reported
inside. Two railroad workers died. Five victims were treated at the
local community hospital, and no patients were taken to the hospital.
Evacuated patients returned. Outpatients were rescheduled. The missing
inpatient was found in good condition; he had hidden in a bathroom and
covered himself under a water-soaked bed sheet. One veteran patient who
was evacuated to the shelter area experienced shortness of breath.
Although medical records were sent with the patients, not all scheduled
medications were obtained prior to the hasty evacuation. A nurse
consulted the hospital, and took the patient's chart into a local
pharmacy. The prescribed inhaler was obtained, and the patient responded
appropriately to the treatment.

6\. *Bombing With Prior Threat Example.*

a\. Background - 640-bed hospital providing general medical,
psychiatric, nursing home and rehabilitation services. There are eight
patient care buildings located on over 150 acres.

b\. Initial Situation - After returning from break on Tuesday morning,
the hospital Director's secretary receives a telephone call from an
irate male. The caller states that he wants to talk to the Director. The
secretary informs the caller that the Director is in a meeting. The
secretary offers to listen to the caller's concerns and assist in
resolving the problem. At this point, the caller curses and terminates
the conversation. Although shaken and irritated, the secretary resumes
her regular duties. Approximately ten minutes later, the man calls the
secretary. He now informs her that he "has had tolerated too much
mistreatment by the hospital," and he intends to "blow up the place."
The secretary quickly opens the medical center's telephone directory to
the Bomb Threat section. The secretary remains calm, and tells the
caller that she will be pleased to assist him if he would tell her his
name. The caller replies Ralph, and then pauses. He again curses,
accuses her of tricking him and terminates the call. The secretary calls
the hospital police.

c\. Initial Situation Questions and Issues Needing Resolution -

1)  Safety of hospital patients, visitors and staff.

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1)  Continuity of patient care.

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1)  Preservation of hospital property.

2)  What are the media issues?

3)  What are the mental health issues?

d\. Information About the Continuing Situation - The Emergency
Operations Center was activated with the hospital Director as Incident
Commander. The hospital's Chief of Police advised the local police bomb
squad as to the hospital's current situation. Hospital police initiated
measures to increase security. All Service Chiefs were briefed. The
hospital Director stated that the bomb threat was not to be discussed
with additional staff, patients or visitors unless another threatening
call is received. A plan to systematically search each building was
readied. Discussions were held concerning potential evacuation of
patients and treatment of casualties. The Associate Chief of
Staff/Ambulatory Care requested that outpatient clinic schedules be
canceled; the Chief of Staff denied this request. Wednesday morning a
Library Service employee called the hospital Police regarding a man
carrying a suitcase and entering a third floor shower room. This
individual was reported because he "seemed to be sneaking around." At
this time, 24 hours have passed since "Ralph's" initial (two) calls; he
has not called again. Most employees and many of the patients have heard
rumors concerning the bomb threat. Several employees used sick leave.
Some patients became agitated, and five inpatients left the hospital
against medical advice. A local radio station called regarding the bomb
threat.

e\. Continued Situation Questions and New Issues -

1)  Continue planning for safety of individuals and hospital property.

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1)  Continue patient care.

f\. Summary - Hospital police apprehended the individual in the shower
room. He was a psychiatric patient who had wandered from his room. He
was returned before the nursing unit noticed his absence. At 3:30pm,
Wednesday, the Medical Center Director publicly announced that the
hospital had received a bomb threat on Tuesday morning. The local media
stated that this situation was managed poorly. Many employees and the
local Service Organizations questioned the "secretive handling of this
incident." This hospital never received another threatening call from
"Ralph."

7\. *Earthquake Example*.

a\. Background - This 1500-bed hospital provides medical, surgical and
psychiatric services, and is affiliated with a large medical school. It
is located in an area frequently impacted by earthquake activity. All
structures on the grounds meet seismic building codes.

b\. Initial Situation - The weather forecast is dry with a daytime high
of 80º and nighttime low of 65º. At 2:50 p.m. Wednesday, an earthquake
measuring 5.0 in magnitude and lasting 8 seconds rattles the hospital.
The epicenter was one mile north. Extensive damage occurred to elevated
highways and utilities. The hospital's Emergency Operations Center (EOC)
is activated, and the Associate Director serves as Incident Commander.
The hospital Director is in another state. The hospital's emergency
power generator starts. It is obvious that the facility has sustained
structural damage. Broken water pipes have caused water to pour through
the ceilings and down the stairs. Debris litters the halls. All
telephone lines are flooded with incoming and outgoing calls, as well as
internal damage reports.

c\. Initial Situation Questions and Issues Needing Resolution -

1)  Accountability and safety of patients, visitors and staff.

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1)  Continuity of patient care.

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1)  Assessment of damage.

2)  What are the media issues?

3)  What are the mental health issues?

d\. Information About the Continuing Situation - Two hours after the
initial earthquake, little information concerning the extent of damage
to the area is known. Communications have been disrupted. Cellular and
landline telephones have not been effective. Most information has been
obtained from watching CNN. At this time, the damage report in the EOC
follows:

1)  There is little structural damage to the north and south wings, but
    extensive damage to the east and west wings.

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1)  Leakage from water, natural gas and medical gas lines has been
    contained.

2)  Many electrical power lines are exposed, and the facility is using
    its emergency power system.

3)  Other than the Director's Office, no Service has reported the status
    of their personnel.

4)  The only information concerning the patients is that many have been
    evacuated to the front lawn area. Staff and ambulatory patients
    assisted in the evacuation process. The floor above the Surgical
    Intensive Care Unit collapsed, and it appears that there will not be
    any survivors from this area. Records indicate that there were 1213
    inpatients and approximately 300 outpatients at the time of the
    incident.

    -   Approximately 100 victims from the neighborhood have walked or
        have been carried to the hospital, and request emergency medical
        care. Most injuries are lacerations and contusions. A few
        individuals have more extensive injuries.

    -   The Medical Laboratory and Dental Services report that their
        areas have sustained severe damage and cannot be operational for
        a long time. Other Services report that there has been damage,
        but some Services can be restored in a day or two.

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1)  Several small fires have been reported. Employees or patients have
    used extinguishers to control all incidents.

2)  Hospital Police reported that two young males forced their way into
    the Credit Union, and escaped with an undetermined amount of cash.

3)  Nuclear Medicine and two research laboratories state that hazardous
    material contamination has occurred.

4)  One patient has barricaded himself in his room, and refuses to
    leave.

e\. Continued Situation Questions and New Issues -

1)  Shelter, food and immediate/continued medical care for the patients.

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1)  Humanitarian role for the general public.

 

f\. Summary - The time is 30 days after the incident, and aftershocks
continue. The President declared the city to be a disaster area.
Federal, state and local agencies mounted a massive response effort.
Fourteen hospital staff and 17 patients died as a result of this
earthquake. Patients were transported by ambulances, buses, vans and
automobiles to surrounding hospitals. Patients that were extremely
medically compromised were placed in the closest available medical
facility. Two hundred thirty ambulatory patients could not be placed in
area medical facilities until the evening following the initial quake.
These individuals received shelter through the American Red Cross. Six
staff, including the Chief of Psychiatric, were severely injured and are
expected to remain off duty for at least another 30 days. One patient
remains missing. One hundred sixty local individuals received emergency
treatment during the first 12 hours. Federal Urban Search and Rescue
Teams feel confident that all victims have been extricated.

The facility will remain unused until a decision is reached regarding
demolition and repair. Social Work Service, Crisis Counseling and
Pharmacy have mobile offices on site. Chronic medications are being
supplied through a consolidated mail-out pharmacy vendor. Many patients
are seeing private physicians or are inpatients in other hospitals
through a contract agreement. The hospital staff have been reassigned to
surrounding hospitals, since all facilities are operating at maximum
capacity (i.e., outpatient clinics operate from 7:00am-12:00am and
inpatient census is 100%).

8\. *Pandemic Influenza Example.*

a\. Background.

1\) [VISN Scenario]{.underline}: VISN XX is responsible for 6 medical
centers and 25 community based outpatient clinics. Services provided
include acute care, ,inpatient,, and outpatient care, mental health
care, long-term care and specialty care. Most of the facilities are
located in densely populated urban areas and served by two major
international airports.

2\) [Facility Scenario:]{.underline} Facility XX is located in an urban
area and is part of a larger VA health care system of two other VAMCs.
The hospital provides full service care, including and emergency
department and is associated with six CBOCs, and one long-term care
site.

b\. Initial Situation - Around the globe, the media cover an
ever-growing number of pandemic influenza stories depicting masses of
ill people descending on healthcare facilities. Similar stories from
early-affected U.S. states are also being reported. The pandemic is
spreading to a growing number of countries and to additional U.S.
states. Pandemic vaccine is still not available and it is estimated that
it will not become available for three months. Pre-pandemic vaccine
(that was stockpiled for a pandemic of this viral subtype) was given to
a few key critical infrastructure workers, including some of Facility
XX's clinicians, but this vaccine's effectiveness at preventing illness
is not certain, since influenza virus mutates so rapidly. An
eight-week's supply of antivirals have been distributed to healthcare
worker staff at VA healthcare facilities according to national guidance,
with instructions to not begin taking them until the pandemic has
reached this area and not to give them to others. Facility XX , the
CBOCs, and the long-term care staff were told to begin daily antiviral
prophylaxis two days ago. Schools have closed, public gatherings are
cancelled, and children and teenagers have been instructed to stay home
and not congregate. Adults are asked to telework as much as possible, or
to practice 'social distancing' at work \-- avoiding meetings, and
wearing appropriate personal protective equipment depending on their
level of public contact, following CDC guidelines. It appears that the
pandemic is beginning in the vicinity of Facility XX. An unusually large
number of cases with fever and cough are reporting to the emergency
departments in your city and VISN area. The state public health
laboratory identifies the pandemic influenza viral subtype in specimens
from VA patients. Private and public hospitals are reporting similar
increases in patients. VA is triaging ill patients in person and over
the phone, treating those with symptoms with antivirals delivered by
local courier volunteers or via overnight delivery services. VA is
instructing household members of their ill patients on where and how to
obtain prophylactic antivirals from the local health department, also
following national community mitigation guidance. VA staff are also
finding that nearly every patient wants a supply of antivirals "just in
case" and many are appearing at the VA to make their requests, prompting
concern that the mixing of uninfected persons with infected at
healthcare sites is propagating the epidemic. All healthcare sites in
the region are reporting the same situation. At this rate, the demand
for antiviral medications will quickly exceed the supply. VA, other
healthcare sites, local leaders, and national leaders are delivering the
same messages (through use of multiple media) about influenza self care,
mental health self care, when to seek professional care, appropriate use
of antivirals, and home quarantine guidance.

c\. Initial Situation Questions and Issues Needing Resolution -
Operational plans need to be initiated regarding the following high
priority issues. Responses and this exercise should involve how VA will
work with local community public health and emergency preparedness
partners.

-   Surge Capacity

-   Risk Communication

-   Disease Control

-   Compliance with federal/local public health guidance

d\. Information about the Continuing Situation - The outbreak of the new
strain of influenza continues, four weeks from when the first cases
started in the area. Cases are still occurring steadily, but the public
seems to have become used to the rules of pandemic operations, and it
appears that the majority are following guidance for social distancing
and use of antivirals. The mortality rate is high, estimated to be
around 2.5% and appears to be highest in 18-40 year olds. Abbreviated
funerals and waiting days for burials or cremations is commonplace.
Private pharmacies, healthcare providers, and some hospitals across the
state are reporting that they are completely out of antiviral
medications and other critical supplies, and are requesting additional
supplies from state and Federal stockpiles, including VA. The absentee
rate of doctors, nurses, other healthcare staff and other critical
infrastructure staff has been steady at 20-30%, either because they are
ill, recovering, grieving, or helping family members. There are periodic
local shortages of gasoline, and foods like bread, milk, and produce.
Internet service is also periodically unavailable, despite national
guidance to all to limit high bandwidth use, like downloading videos.
This affects money transfers, availability of funds after check
depositing, and ATM transactions. The public is uneasy about the
dangerous illness, the limited public interaction allowed, and the
shortages, but frequent televised messages from the President, the
Director of the CDC, and the Governor discussing the pandemic's progress
are highly anticipated by the public each day. VA, following the
Incident Command Structure, is working to maintain its missions while
handling the multitude of situations going on at its facilities and
offices around the country VA and public police/security are very
concerned about safeguarding resources that are in high demand as they
hear reports of thefts and hijackings of transport vehicles around the
country.

e\. Continued Situation Questions and New Issues - Facilities need to be
prepared to address the issues of:

-   Resource Sharing and Resource Shortages

-   Alternative Modes of Operations

-   Workforce Challenges

-   Functioning of ICS

f\. Summary - VA facilities have prepared themselves for multiple waves
of the new influenza strain. VA's national, VISN and facility websites
have posted the latest guidance and information, and have enhanced their
telephone advice lines. Surveillance data is being collected nationally
through CDC and VA's surveillance systems. Collaboration with the local
community is ongoing related to risk communication, vaccine
distribution, and antiviral distribution. Facilities continue to need
additional Personal Protective Equipment for staff; screen incoming
patients for influenza-like illness; implement visitor restrictions
policies based on local decisions and follow other public health
measures. Facilities have expanded and used alternative space for
triage, diagnosis and isolation of infected patients; continue to track
supplies and attempt to purchase supplies that are in short supply. Mass
fatality plans need to be revisited as storage sites for deceased
victims are reaching capacity. Administrative staff teleworking from
home appears to be mostly successful. Accurate and timely communication
to all staff, patients and the community is critical to the success of
addressing the ongoing situations.

J. Enclosures

9-1. Appendix C, Competency Framework and Recommendations for a Health
System Emergency Management Certification Program.

9-2. New Employee Orientation Guideline for Emergency Program Managers

9-3. Example VA/DoD Exercise

9-4. Example Federal/State/Local Exercise Plan

> Annex A - Level of Participation
>
> Annex B - Exercise Observers
>
> Annex C - Communications
>
> Annex D - Security
>
> Annex E - Public Affairs
>
> Annex F - Brief Scenario Template

9-5. Example Exercise Area Diagram

9-6. Tabletop Exercise Template

9-7. Example Tabletop PowerPoint Template

9-8. Example Exercise Critique/After Action Report

9-9. FEMA's Guide to Emergency Exercises

9-10. Recommendation for Certification Program

9-11. Example Tabletop Exercise - Pandemic Flu