Section 5

Sample Readiness Plans for Specific Incidents

Table of Contents

-   **Part l - Sample Healthcare First Receiver Decontamination
    Readiness Plan**

5.1.1. Introduction 5-1-1

5.1.2. Purpose 5-1-1

5.1.3. Scope 5-1-1

5.1.4. Policy 5-1-1

5.1.5. Responsibilities 5-1-2

5.1.6. Planning 5-1-2

5.1.6.1. Community Role 5-1-2

5.1.6.2. Risk Assessment 5-1-3

5.1.6.3. Personnel Resources 5-1-3

5.1.6.4. Personal Protective Equipment (PPE) 5-1-3

5.1.6.5. Training 5-1-3

5.1.6.6. Exercise and Drills 5-1-4

5.1.6.7. Decontamination Facilities and Equipment 5-1-4

5.1.7 Emergency Response 5-1-4

5.1.7.1. Activate Emergency Operations Center (EOC) 5-1-4

5.1.7.2. Decontamination 5-1-5

5.1.8. Recovery Planning 5-1-5

-   **Part 2 - Sample Biologic Event and Terrorism Readiness Plan**

5.2.1. Introduction 5-2-1

5.2.2. Purpose 5-2-2

5.2.3. Scope 5-2-2

5.2.4. Policy 5-2-2

5.2.5. Notification Processes and Contact Information 5-2-3

5.2.5.1. Internal Facility Contact Numbers 5-2-3

5.2.5.2. External Contacts 5-2-3

5.2.6. CDC Category A, B and C Select Agents 5-2-4

5.2.6.1. CDC Category A Biologic Agents 5-2-4

5.2.6.2. CDC Category B Biologic Agents 5-2-4

5.2.6.3. CDC Category C Biologic Agents 5-2-5

5.2.7. Unique Pathogens with Potential for Epidemic and/or Pandemic
Events 5-2-5

5.2.8. Overview of Infection Control Activities 5-2-6

5.2.8.1. Detection of Outbreaks Caused by Biologic Agents 5-2-6

5.2.8.2. CDC-Defined Nationally Reportable Pathogens 5-2-6

Table 5-2.1: Nationally Reportable Pathogens List 5-2-7

5.2.8.3. Passive Surveillance 5-2-8

5.2.8.4. Active Surveillance 5-2-8

5.2.8.5. Syndrome-Based Criteria 5-2-9

Table 5-2.2: Clinical Syndromes in the Bioterrorism Event 5-2-9

5.2.8.6. Epidemiologic Features 5-2-11

5.2.9. Special Considerations for Mission Critical Engineering Systems
5-2-11

5.2.10. Infection Control Practices for Patient Management 5-2-12

5.2.10.1. Isolation and Standard Precautions 5-2-12

5.2.10.2. Handwashing 5-2-12

5.2.10.3. Gloves 5-2-13

5.2.10.4. Gowns 5-2-13

5.2.10.5. Face Protection 5-2-13

5.2.10.6. Respiratory Protection 5-2-13

5.2.10.7. Patient Placement 5-2-13

5.2.10.8. Respiratory Isolation 5-2-14

5.2.10.9. Patient Transport 5-2-14

5.2.10.10 Cleaning, Disinfection and Sterilization of Equipment and
Environment 5-2-14

5.2.10.11 Discharge Management 5-2-15

5.2.11. Post-Exposure Management 5-2-15

5.2.11.1 Decontamination of Patients and Environment 5-2-15

5.2.11.2 Prophylaxis and Post-Exposure Immunization 5-2-16

5.2.11.3 Triage and Management of Large Scale Exposures and Suspected
Exposures 5-2-16

5.2.11.4 Psychological Aspects of Bioterrorism 5-2-17

5.2.12 Laboratory Support and Confirmation 5-2-18

5.2.12.1 Obtaining Diagnostic Samples 5-2-18

5.2.12.2 Laboratory Level for Handling Biologic Agents 5-2-18

5.2.12.3 Transport Requirements 5-2-18

5.2.12.4 CDC Laboratory Response Network 5-2-18

5.2.12.5 Tissue Handling and Post-Mortem Care 5-2-19

5.2.13. Patient, Visitor and Public Information 5-2-19

5.2.14. Standard Operating Procedures - Potential Agents 5-2-20

5.2.15. Drills and Exercises 5-2-20

*Attachments*

A. FBI Field Offices Contact Listing 5-2-23

B. Response Algorithm - Surveillance Plan (The Symptomatic Patient)
5-2-33

C. Response Algorithm - Biological Event Plan 5-2-34

D. Mission Critical Engineering Systems Considerations 5-2-35

-   **Part 3 - Sample Radiological Event and Terrorism Readiness Plan**

5.3.1. Introduction 5-3-1

5.3.2. Purpose 5-3-1

5.3.3. Scope 5-3-1

5.3.4. Policy 5-3-1

5.3.5. Radioactive Material and Terrorist Events 5-3-1

5.3.5.1. Radiological Dispersal Device (RDD) 5-3-1

5.3.5.2. Nuclear Detonation 5-3-2

5.3.5.3. Irradiation Device 5-2-2

5.3.6. Contamination and Exposure 5-2-2

5.3.6.1. External Contamination 5-3-2

5.3.6.2. Internal Contamination 5-3-2

5.3.6.3. Incorporation 5-3-2

5.3.6.4. Exposure or Irradiation 5-3-3

5.3.7. Adverse Health Effects 5-3-3

5.3.8. Protection of Response Personnel 5-3-3

5.3.8.1. Time, Distance and Shielding 5-3-3

5.3.8.2. Respiratory Protection 5-3-3

5.3.8.3. Skin Protection 5-3-3

5.3.8.4. Dosimetry 5-3-4

5.3.9. Medical Considerations of Contaminated Victims 5-3-4

5.3.10. Decontamination of Victims 5-3-4

5.3.10.1 Skin Decontamination 5-3-4

5.3.10.2 Wound Decontamination 5-3-4

5.3.10.3 Internal Treatment 5-3-5

5.3.11. Radiological Assessment and Biodosimetry 5-3-5

5.3.12. Biodosimetry Assessment Tool 5-3-5

5.3.13. Morgue Operations 5-3-5

5.3.13.1 Autopsies 5-3-5

5.3.13.2 Embalming/Cremation 5-3-6

5.3.14. Psychological Aspects of a Radiological Event 5-3-6

5.3.15. Exercise Scenarios 5-3-6

5.3.15.1. Radiological Dispersal Device (Dirty Bomb) 5-3-6

5.3.15.2. Improvised Nuclear Device (IND) 5-3-6

*Attachment*

A. Radiological Performance Evaluation Matrix 5-3-8

-   **Part 4 - Sample Chemical Event and Terrorism Readiness Plan**

5.4.1. Introduction 5-4-1

5.4.2. Purpose 5-4-3

5.4.3. Scope 5-4-3

5.4.4. Policy 5-4-3

5.4.5. Notification Processes and Contact Information 5-4-3

5.4.5.1. Internal Facility Contact Numbers 5-4-3

5.2.5.2. External Contacts 5-4-4

5.4.6. United Nations Hazard Classes 5-4-4

Table 5-4.1: United Nations Hazard Classes 5-4-5

5.4.7. Pre-Planning Considerations for Chemical Events 5-4-6

5.4.7.1. Facility Lockdown 5-4-6

5.4.7.2. Secondary Events 5-4-6

5.4.7.3. Police and Security 5-4-6

5.4.7.4. Interlinking Response Plans and SOPs 5-4-7

5.4.7.5. Syndrome-Based Criteria 5-4-7

Table 5-4.2: Clinical Syndromes in a Chemical Event 5-4-8

5.4.7.6. Matrix-Based System for Agent Categorization 5-4-8

Table 5-4.3: Chemical Agent Indicator Matrix 5-4-9

5.4.7.7. Special Considerations for Mission-Critical Engineering Systems
5-4-10

5.4.8. Post-Exposure Management 5-4-10

5.4.8.1. Decontamination of Patients and Environment 5-4-10

5.4.8.2. Triage and Management of Large Scale Exposures and Suspected
Exposures 5-4-11

5.4.8.3. Psychological Aspects of a Chemical Terrorism Event 5-4-11

5.4.9. Laboratory Support and Confirmation 5-4-12

5.4.9.1. Obtaining Diagnostic Samples 5-4-12

5.4.9.2. Transport Requirements 5-4-12

5.4.9.3. CDC Laboratory Response Network 5-4-13

5.4.9.4. Tissue Handling and Post-Mortem Care 5-4-13

5.4.10. Patient, Visitor and Public Information 5-4-13

5.4.11. Drills and Exercises 5-4-13

-   **Part 5 - Sample Trauma Readiness for All-Hazards Disaster Response
    Plan**

5.5.1. Introduction 5-5-1

5.5.2. Purpose 5-5-3

5.5.3. Scope 5-5-3

5.5.4. Policy 5-5-3

5.5.5. Notification Processes and Contact Information 5-5-3

5.5.5.1. Internal Facility Contact Numbers 5-5-4

5.5.5.2. External Contact Numbers 5-5-5

5.5.5.3. Initial Notification to Network Director 5-5-5

5.5.6. Responsibilities 5-5-5

5.5.7. Mass Casualty Event Trauma 5-5-7

5.5.8. Trauma Control Practices for Patient Management 5-5-8

5.5.9. Infection Control Practices and Standard (Universal) Precautions
5-5-8

5.5.10. Triage and Management of Large Scale Mass Casualty Trauma
Incidents 5-5-9

5.5.11. Trauma Management in the Grossly Contaminated Patient 5-5-10

5.5.12. Discharge Management of the Trauma Patient 5-5-10

5.5.13. Psychological Aspects of Trauma 5-5-10

-   **Part 6 - Special Considerations**

> A. **Sample Chain-of-Custody Readiness Plan**

5.6.1. Introduction 5-6-1

5.6.2. Physical Evidence 5-6-1

5.6.2.1. Policy and Security 5-6-1

5.6.2.2. VA Handbook 7030 5-6-1

5.6.2.3. VA Form 3524 5-6-1

5.6.3. Biological Specimens 5-6-1

5.6.3.1. General 5-6-1

5.6.3.2. Crime Scene 5-6-2

5.6.3.3. Forms 5-6-2

5.6.4. Environmental Samples 5-6-2

5.6.4.1. Collecting Samples 5-6-2

5.6.4.2. Labeling 5-6-3

5.6.4.3. Identification of Samples 5-6-3

5.6.4.4. Sample Seals 5-6-3

5.6.4.5. Forms 5-6-3

5.6.4.6. Analytical Results 5-6-4

5.6.4.7. Disposition of Sample 5-6-4

> B. **Sample Pharmacy Cache Readiness Plan**

5.6.5. General 5-6-4

*Attachments*

A. VA Form 3524, Evidence or Property Custody Record 5-6-7

B. VA Form 10-0018, Air Sample Data Sheet 5-6-9

-   **Part 7 - New FEMA (FPC 65) Requirements for VAMC Continuity of
    Operations Plans (COOP)**

> 5.7.1. Purpose 5-7-1
>
> 5.7.2. Background 5-7-1
>
> 5.7.3. Applicability and Scope 5-7-1
>
> 5.7.4. Relationship with the Emergency Operations Plan (EOP) 5-7-1
>
> 5.7.5. Developing COOP Plans and Procedures 5-7-2
>
> 5.7.5.1. Overall Process 5-7-2
>
> 5.7.5.2. Service-Level COOP Planning 5-7-2
>
> 5.7.5.2.1. Functional Description 5-7-2
>
> 5.7.5.2.2. Functional Responsibilities 5-7-2
>
> 5.7.5.2.3. Requirements for Continuity of Operations 5-7-2
>
> 5.7.5.3. Organization-Level COOP Planning 5-7-5
>
> 5.7.5.3.1. Executive Summary 5-7-5
>
> 5.7.5.3.2. Introduction 5-7-5
>
> 5.7.5.3.3. Purpose 5-7-5
>
> 5.7.5.3.4. Applicability and Scope 5-7-6
>
> 5.7.5.3.5. Essential Functions 5-7-6
>
> 5.7.5.3.6. Authorities and References 5-7-7
>
> 5.7.5.3.7. Concept of Operations 5-7-8
>
> 5.7.5.3.8. Orders of Succession 5-7-9
>
> 5.7.5.3.9. Delegations of Authority 5-7-10
>
> 5.7.5.3.10. Devolution 5-7-11
>
> 5.7.5.3.11. Vital Files, Records and Databases 5-7-11
>
> 5.7.5.3.12. Logistics 5-7-12
>
> 5.7.5.3.12.1. Alternate Care Site 5-7-12
>
> 5.7.5.3.12.2. Interoperable Communications 5-7-12
>
> 5.7.5.3.13. Test, Training and Exercises 5-7-13
>
> 5.7.5.3.14. Plan Maintenance 5-7-13
>
> 5.7.5.3.15. Annexes 5-7-13

Section 5 - Part 1

Sample Healthcare First Receiver

Decontamination Readiness Plan

5.1.1. ***Introduction.*** The Healthcare First Receiver Decontamination
Readiness Plan (DRP) is a component of the Emergency Management Plan
(EMP). The design of the Healthcare First Receiver Decontamination
Readiness Plan is based on the VA Medical Center's (VAMC) role in the
community, regulatory and VHA requirements, and perceived threats from
both within and outside the VAMC that may require activation of VAMC's
Healthcare First Receiver Decontamination Readiness Plan.

5.1.2. ***Purpose.*** To describe how the VAMC will respond to emergency
threats or events that may involve decontamination. The Healthcare First
Receiver Decontamination Readiness Plan will address policy
requirements, resources and processes for a VAMC-wide response to
hazardous materials events that require decontamination and treatment of
victims.

5.1.3. ***Scope.*** This sample Plan will define the medical center's
role in the community; applies to all employees; ensures compliance with
regulatory and industry standards; and implements the VAMC strategy for
responding to hazardous material events. It is designed to prepare staff
to respond and protect the well being of patients, employees and all
occupants within the VAMC; protect the physical infrastructure; and
allow for business continuity to the fullest extent possible.

5.1.4. ***Policy***. VHA Memorandum, dated February 3, 2003 (Subject:
Notification of Selection for VA's Mass-Casualties Decontamination
Program) and VHA Directive 2003-045 (Subject: Steps Required to
Establish a Practical Medical Center Emergency Mass-Casualty
Decontamination Capability) provided a blueprint for planning and
implementing a Decontamination Program at VA Medical Centers. In
December 2004, the Occupational Safety and Health Administration (OSHA)
published its "Best Practices for Hospital Based First Receivers of
Victims from Mass Casualty Incidents Involving the Release of Hazardous
Substances." It is the policy of this medical center to comply with the
above (Memorandum, Directive and OSHA guidance) in planning for and
responding to a hazardous material event that may include one or more
chemical, biological and radiological agents, industrial chemicals or
naturally occurring biological agents. Based on VHA policy, regulatory
requirements and local facility needs, the VAMC will:

1\. Develop a Healthcare First Receiver Decontamination Standard
Operating Plan (SOP) (see sample SOP in Section 6.3.3.2.) to include, as
appropriate, specific event readiness plans (see Parts 2-6 of this
Section) and all other related SOPs (Section 6).

2\. Upon notification, activate the Emergency Operations Plan to make
certain the necessary services are provided to ensure a safe environment
for all occupants.

3\. Initiate the decontamination response plan and related SOP's as
appropriate.

5.1.5. ***Responsibilities***. The VAMC will coordinate with the
community to ensure effective interaction during response and recovery.
In addition:

-   *Medical Center Director or Designee* is responsible to act as the
    Incident Commander/Manager (IC), and is responsible for all VAMC
    response planning and actions.

-   *Emergency Program Coordinator (EPC) or Designee* is responsible to
    ensure that the Decontamination Program is current and assists the
    IC with internal (Key Operations Managers) and external (community
    or agency) coordination.

-   *Chief of Staff* is responsible for providing proper medical, health
    and treatment care services.

-   *Associate Director* is responsible for monitoring and ensuring VAMC
    operations and services as they relate to patient services are
    implemented.

-   *Safety Officer* is responsible for monitoring and initiating
    actions to ensure safe actions are taken during the emergency event.

-   *Public Affairs* will act as the point of contact for the media and
    other governmental agencies that may request information concerning
    the incident and its impact upon patients, staff and facility.

-   *Police Chief* ensures that lockdown and security procedures,
    traffic and crowd control, crime scene and investigation, chain of
    custody and perimeter control are implemented.

-   *Chief Engineer* is responsible for protecting, repairing and
    maintaining plant utility systems, communications and medical
    equipment necessary for patient care and VAMC operation.

-   *Chief A&MMS* is responsible for logistical function as it relates
    to providing facilities, transportation, supplies, equipment,
    services, etc.

-   *Chief Fiscal* is responsible for providing funding and tracking
    expenses that relate to VAMC response to the emergency event.

5.1.6. ***Planning.*** As stated in VHA Directive 2003-045, each medical
center is responsible for implementing an appropriate mass-casualty
decontamination program. The most important piece of the program is to
understand the medical center's community role. This understanding will
dictate what steps must be taken to develop a decontamination program,
and whether the facility is expected to receive casualties from an
external emergency event or not. Areas to be addressed include:

5.1.6.1. **Community Role**: Whether or not the medical center will be
involved in decontamination procedures will depend on the medical
center's capability to accomplish decontamination, and the current
expectations of the community, e.g., city, county and state emergency
plans.

1\) If there are no expectations from either the medical center or
community, ensure that the medical center is not expected to receive
contaminated victims, and identify those healthcare facilities that
will.

2\) If the facility is designated to receive casualties, the following
issues must be addressed: (Note: See sample Healthcare First Receiver
Decontamination Standard Operating Procedure (SOP) and attachments for
in-depth review in Section 6.3.3.2.)

-   Personnel required to be trained at the Awareness Level.

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-   Personnel required to be trained at the Operations Level.

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-   Number and type of Personal Protective Equipment (PPE).

-   Type of decontamination equipment, location and accessibility.

-   Decontamination capability for both ambulatory and non-ambulatory
    casualties.

-   Response and Recovery procedures.

5.1.6.2. **Risk Assessment**: The Healthcare First Receiver
Decontamination SOP discusses risk assessment procedures under the
mitigation/preparedness section. This assessment is critical to the
planning process and selection of decontamination equipment including
PPE.

5.1.6.3. **Personnel Resources**: Developing and maintaining a
decontamination team is the most critical element in having a viable
decontamination and treatment program. Most medical centers that have
achieved success have done so with volunteers. Top management must be in
full support of the decontamination program for it to succeed.
Developing and cultivating team interest will be the challenge for the
medical center to steadily improve. It is important to choose those who
will lead and watch out for the interest of the program. Examples of
decontamination personnel assignments are identified in the SOP. A
PowerPoint presentation on team building is included as an Attachment to
the sample Healthcare First Receiver Decontamination SOP.

4.  **Personal Protective Equipment (PPE)**: VHA has determined that
    Level C, utilizing Powered Air Respirators (PAPR) with combination
    cartridges (OV, AG, P-100), can be used as minimum protection for
    hospital receivers conducting decontamination. This is based on the
    following assumptions:

-   The event that requires decontamination is remote from the release
    site and/or emergency event.

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-   A risk assessment (RA) has been conducted to include community and
    internal hazardous materials.

-   All persons required to wear PPE have been trained at the Operations
    Level in accordance with OSHA 1910.120 and OSHA document titled
    *OSHA Best Practices for Hospital-Based First Receiver for Victims
    from Mass Casualty Incident Involving the Release of Hazardous
    Substances*, December 2004, with emphasis on decontamination.

-   All persons wearing PPE have been evaluated under the medical
    center's Respiratory Protection Program.

5.1.6.5. **Training**: All healthcare employees who participate in an
event that requires decontamination must receive Hazard Awareness
Training in accordance with OSHA 29 CFR 1910.120. OSHA requires that
hospital receivers who are expected to wear PPE shall be trained at the
Operations Level (e.g., must have a minimum of 8 hours of training
and/or demonstrate Operations Level Competencies). In addition, the
training must meet the core requirements of VHA's Decontamination
Training Program.

5.1.6.6. **Exercise and Drills**: Memorandum from Chief Officer, Office
of Public Health and Environmental Hazards, dated February 3, 2003,
stated that at least two decontamination exercises should be conducted
annually to maintain decontamination readiness. Every effort must be
made to ensure that the exercises are appropriate to test the medical
center's capabilities. Involvement with community exercises is
encouraged. (See Exercise Examples in Section 9 for additional
information.)

5.1.6.7. **Decontamination Facilities and Equipment**: Each medical
center must determine the type of decontamination facility and related
equipment required to support its community role and mission.
Decontamination facilities may be fixed or portable. The size of the
decontamination facility will determine the number of people who can be
decontaminated over a period of time. Other considerations must include
ventilation, water temperature, water containment, items used for
washing rinsing activities, equipment to secure contaminated clothing
and personal items, etc.

5.1.7. ***Emergency Response***. Whenever an emergency event or threat
occurs that may require activation of the Healthcare First Receiver
Decontamination Readiness Plan, the Incident Commander (IC) or designee
will acquire information as to the type event and potential impact to
the VAMC. If the IC decides the emergency event will or may have an
adverse impact to the VAMC, he or she will activate the Emergency
Operations Plan (EOP), which will then require the activation of
appropriate SOP's.

5.1.7.1. **Activate Emergency Operations Center (EOC)**. The IC or
designee will notify telephone operators to contact the EOC members
(listed below) and direct them to report to the EOC (insert VAMC EOC
building/room number
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ and phone number
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_).

Chief of Staff Contacted: Yes\_\_\_\_ No\_\_\_\_

Associate Medical Center Director Contacted: Yes\_\_\_\_ No\_\_\_\_

Decon Coordinator Contacted: Yes\_\_\_\_ No\_\_\_\_

Chief Nursing Contacted: Yes\_\_\_\_ No\_\_\_\_

Chief Pharmacy Contacted: Yes\_\_\_\_ No\_\_\_\_

Public Affairs Officer Contacted: Yes\_\_\_\_ No\_\_\_\_

Chief Engineering Contacted: Yes\_\_\_\_ No\_\_\_\_

Chief Police Contacted: Yes\_\_\_\_ No\_\_\_\_

Safety Officer Contacted: Yes\_\_\_\_ No\_\_\_\_

Chief A&MMS Contacted: Yes\_\_\_\_ No\_\_\_\_

Area Emergency Manager (AEM) Contacted: Yes\_\_\_\_ No\_\_\_\_

5.1.7.2. **Decontamination**. If the IC or designee determines that
decontamination is needed, the following actions will be implemented:

1\) Activate the Healthcare First Receiver Decontamination SOP. (Note:
decontamination activities may include activation of other related
Readiness Plans and SOPs that involve the following:

-   Terrorist Threats, Section 6.2.2.5.

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-   Biological Events, Section 6.2.3.1.

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-   Chemical Events, Section 6.2.3.2.

-   Radiation Exposure or Radioactive Contamination, Section 6.2.3.3.

-   Trauma Management in a MCI/Blast and Explosions, Section 6.3.3.5.

-   VHA Pharmacy Cache, Section 5, Part 6B.

-   Triage During a Mass Casualty Incident, Section 6.3.3.4.

-   Chain of Custody, Section 5, Part 6A.

-   Lockdown/Security - Heightened Security Procedures, Section 6.3.4.3.

2\) Notify Network and, if appropriate, VHA Central Office authorities.

3\) Notify and coordinate action with appropriate outside agencies.

5.1.8. ***Recovery Planning.*** Decontamination operations involve
considerable recovery actions. These may include:

-   \*Decontaminating equipment and PPE.

-   \*Decontaminating or securing sections of the healthcare facility
    that may have been contaminated due to failure of security or other
    actions not anticipated.

-   \*Decontaminating items that present a hazard to others. Examples
    include individual vehicles used to deliver contaminated victims,
    personal items, etc.

-   \*Analyzing and proper disposal of contaminated wastewater used in
    decontaminating operations.

-   Ensuring the well being of persons involved with decontaminating
    functions, as well as those who were possible victims.

-   Ensuring all emergency equipment and supplies are replenished and
    readied for future emergencies.

-   Conducting After Action Reports to include facility and community
    response.

Note: \* Decontamination activities may be conducted by the medical
center, other federal agencies or an outside contractor.

Section 5 - Part 2

Sample Biologic Event

And Terrorism Readiness Plan

5.2.1. ***Introduction***. The Biologic Event and Terrorism Readiness
(BETR) Plan is a component of the VA Medical Center (VAMC) Emergency
Operations Plan (EOP) that addresses the unique special considerations
of dealing with a biologic disaster. The BETR plan is to be used for any
biologic hazard or threat, naturally occurring or intentional, that may
be encountered by the VA Medical Center; external biologic emergencies
declared by the VA/Department of Defense (DoD); and any community
emergency event that the VA Medical Center may be asked to assist with.
The plan is structured to use the Incident Command System (ICS) and
implement Standard Operating Procedures (SOPs) for any specific biologic
event that is likely to be encountered.

Hospitals and acute care clinics are anticipated to be the initial site
for recognition that a biologic event (either natural outbreak or
terrorist related incident) has occurred. Epidemiology is part of daily
routine for most providers, as they collect historic patient data for
medical record documentation. Aggregations of this data through
bio-surveillance programs help expedite recognition of outbreaks.
Biological agents have specific characteristics that define appropriate
clinical and public health responses. The goals of an effective biologic
event response plan are to block the trail of agent exposure, thus
minimizing impact to the community, facility, patients and hospital
staff; provide safe and effective treatment for patients and exposed
staff; and communicate effectively both internally and externally,
maximizing awareness and minimizing panic. The Medical Center Infection
Control team, along with clinical leadership, hospital administration,
Engineering and Clinical Laboratory service working together as a team,
make an effective biologic event plan possible.

Important characteristics of biological organisms include mode of
transmission, infectious period, transmission rate and incubation
period, which define the pattern of spread; and, together with person
density and contact frequency, the shape of an epidemic curve. The
availability of vaccines, their effectiveness and whether they may be
administered after exposure often delimit mitigation strategies. The
availability of effective pharmacological agents for treatment of
established cases or prophylaxis, along with availability of other
critical resources and engineering controls such as respiratory
isolation capacity and personal protective equipment (PPE), may delimit
the management of individual cases. Knowledge of these characteristics
and resources allows the development of an effective response plan.

VAMC facilities must have infection control policies in place
authorizing the appropriate staff to rapidly implement prevention and
control measures in response to a potential or suspected biologic event.
Should a bioterrorism event be identified, an effective network of
communication must be activated internally to include Infection Control
personnel, the hospital Director, the Public Affairs Officer, healthcare
providers, hospital Safety, Engineering, Clinical Laboratory personnel
and Environmental Management Service, as well as all clinical and
administrative service chiefs. External notification will include the
Network Director and Public Health agencies, and may be extended to
include the Federal Bureau of Investigation (FBI) field office and the
Center for Disease Control and Prevention (CDC). Notification of other
local medical facilities may also be helpful to ensure that city-wide or
regional-wide awareness levels are increased. The VAMC uses the
Incidence Command Station (ICS) model of disaster response coordination
to ensure effective communication of both situation status reports and
local needs analysis throughout the event. Commitment to periodic
disaster preparedness drills allows testing of program effectiveness and
improvement of response capacity and readiness.

5.2.2. ***Purpose***. The purpose of the Biologic Event and Terrorism
Readiness (BETR) Plan is to describe how the VA Medical Center will
respond to biologic disaster events or naturally occurring biologic
threats. This plan address policy requirements, assumptions and
processes for a VA Medical Center-wide coordinated response that focuses
on safety of the work environment for the protection of our patients,
employees, facility and community.

5.2.3. ***Scope***. This Sample Biologic Event and Terrorism Readiness
(BETR) Plan applies to all employees, ensures compliance with Joint
Commission on Accreditation of Healthcare Organizations (JCAHO)
requirements, and implements the VA Medical Center's strategy for
responding to all potential biologic-related emergency events. It is
designed to respond and protect the well being of patients, employees
and all occupants within the VAMC, protect the physical infrastructure
and allow for business continuity to the fullest extent possible.

Specific sample SOPs based on specific threats thought most likely to be
faced can be found in Section 6.2.3.1. of this Guidebook. As the world
of infectious disease pathogens is so enormous, it is not possible to
have a specific SOP for each agent. For this reason the focus will be on
the type of threats such as environmental threats (e.g. the concentrated
anthrax spore events of 2001 or Legionella contaminating a mission
critical water supply system), anticipated respiratory droplet epidemic
events (e.g. influenza virus or Severe Acute Respiratory Syndrome\--
SARS), or other high risk intentional bioterrorism related risks (e.g.
CDC-defined category A, B or C bioterrorism agents as listed in the
following paragraphs).

This Sample Biologic Event and Terrorism Readiness (BETR) Plan and all
SOPs developed as the result of the Hazard Vulnerability Analysis (HVA),
define the mitigation, preparedness, response and recovery efforts
necessary to minimize the potential adverse impact from the biologic
threats and events most likely to be encountered.

5.2.4. ***Policy***. In the event of a biologic agent emergency or
disaster, the VA Medical Center will implement the Biologic Event and
Terrorism Readiness (BETR) Plan to make certain the necessary services
are provided to ensure a safe environment for all occupants. The VA
Medical Center will work closely with the community to ensure effective
interaction during response and recovery.

5.2.5. ***Notification Processes and Contact Information***. Healthcare
facilities may be the initial site of recognition and response to
bioterrorism events. If a bioterrorism event is suspected, local
emergency response systems should be activated. Notification should
immediately include the facility hospital Director, Infection Control
Officer, healthcare providers, Engineering, hospital Safety Officer,
Clinical Laboratory Director, Environmental Management Service chief and
other clinical and administrative service chiefs.

If appropriate, the Office of the Director will activate the Emergency
Operations Center (EOC) and will coordinate with all internal services,
Network Director, Department of Health, FBI field office, local police,
CDC and medical emergency services. The Infection Control team members
will track and monitor all patients and potential exposed staff,
reporting data through the Office of the Director to the Public Health
Service.

5.2.5.1. Internal Facility Contact Numbers:

Infection Control \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Hospital Director \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Chief of Staff \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Safety Officer \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Clinical Laboratory \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Engineering \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Environmental Management \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Nutrition and Food Service \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

5.2.5.2. External Contacts:

Network Director \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Area Emergency Manager \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Health Department \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Local FBI Field Office\* \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\*(See Attachment A - FBI Field Office Contact Numbers)

CDC Bioterrorism Emergency Response Office ([770) 488-7100)]{.underline}

CDC Hospital Infections Program ([404) 639-6413)]{.underline}

Local Medical Facility Contacts:

University Hospital \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Hospital A \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Hospital B \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Hospital C \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Hospital D \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Initial Notification to Network (VISN) Director should include:

-   Facility Name and Location of event or Impact Area (e.g. Emergency
    Department).

-   Name and position of reporting official.

-   Incident Command station phone number and ICS managers name.

-   Short Situation Report (to include type of biologic event, clinical
    symptoms and level of diagnostic certainty, e.g., suspected agents,
    presumptive diagnosis or culture/PCR confirmed diagnosis).

-   Chronological order of events, to include number of patients
    received to date.

-   Immediate and projected short-term resource needs.

-   Status of Public Health Service notification.

-   Summary of all other agencies or facilities to be notified.

5.2.6. ***CDC Category A, B and C Select Agents***. In addition to the
vast number of pathogens healthcare providers encounter as a part of
daily routine, the threat of terrorist activities mandates that they
also be prepared to encounter pathogens and clinical diseases uncommon
in the United States. With this in mind, the Center for Disease Control
and Prevention has published a categorical listing of biologic pathogens
and toxins, grouped by both unique agent characteristics and the
anticipated probability of these agents being used in an intentional
biologic event. The following paragraphs cover both the definitions of
these categories and the select agents currently listed within each
category.

5.2.6.1. [CDC Category A Biologic Agents:]{.underline} Category A select
agents represent high priority agents, including organisms that pose a
risk to national security because they:

-   Can be easily disseminated or transmitted from person to person;

-   Result in high mortality rates and have the potential for major
    public health impact;

-   Might cause public panic and social disruption; and

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-   Require special action for public health preparedness.

> **Current Category A Agent Listing**

*Bacillus anthracis* (anthrax)

*Francisella tularensis* (tularemia)

*Yersinia pestis* (plague agent)

Smallpox Virus (variola major)

Viral Hemorrhagic Fever Viral Groups

(Filoviruses e.g. Ebola; Marburg)

(Arenaviruses e.g. Lassa; Machupo)

Botulinum toxin (Botulism; from Clostridium botulinum)

5.2.6.2. [CDC Category B Biologic Agents:]{.underline} Category B select
agents represent the second highest priority agents that pose a risk to
national security because they:

-   Are moderately easy to disseminate;

-   Result in moderate morbidity rates and low mortality rates; and

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-   Require specific enhancements of CDC's diagnostic capacity and
    enhanced disease surveillance.

> **Current Category B Listing:**

Brucellosis (*Brucella* species)

Epsilon Toxin (from *Clostridium perfringens*)

Food Safety Threat Agents

*Salmonella* species

*Shigella* species

*Escherichia coli* O157:H7

*Burkholderia pseudomallei* (Meliodosis)

*Chlamydia psittaci* (Psittacosis)

Coxiella burnetii (Q fever)

Ricin Toxin (From castor bean, *Ricinus communis*)

*Staphylococcus Enterotoxin B* (SEB; from *Staphylococcus aureus*)

*Rickettsia prowazekii* (Typhus fever)

Viral Encephalitis (Alphaviruses group)

Venezuelan Equine Encephalitis (VEE)

Eastern Equine Encephalitis (EEE)

Western Equine Encephalitis (WEE)

Water Safety Threats

*Vibrio cholerae*

*Cryptosporidium parvum*

5.2.6.3. [CDC Category C Biologic Agents:]{.underline} Category C select
agents represent the third highest priority agents that pose a risk to
national security because of:

-   Availability;

-   Ease of production and dissemination; and

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-   Potential for high morbidity and mortality rates and major health
    impact.

# Current Category C Agent Listing

Hantavirus (Sin nombre virus of Hantavirus Pulmonary Syndrome)

> Nipah Virus (Swine Upper Respiratory virus that may cause fatal viral
> encephalitis when transmitted to man)

5.2.7. ***Unique Pathogens with Potential for Epidemic and/or Pandemic
Events***. Another group of infectious disease pathogens that could
result in a devastating epidemic or pandemic event includes agents
spread primarily through the respiratory route. Although these agents
are not components of the CDC select agent categories A, B or C,
appropriate infection control responses must be rapidly applied to avoid
a disastrous outbreak or curtail an evolving outbreak. A sample standard
operating procedure for dealing with these respiratory threat pathogens
may be found in Section 6.2.3.1.4. of this Guidebook. Important
infectious disease agents in this category to consider include:

-   Influenza virus A and B

-   Avian Influenza virus

-   Severe Acute Respiratory Syndrome (SARS)

-   Leptospirosis

5.2.8. ***Overview of Infection Control Activities***.

5.2.8.1. *Detection of Outbreaks Caused by Biologic Agents*. Naturally
occurring and terrorist biologic events occur largely as covert events,
in which persons are unknowingly exposed; an outbreak is suspected only
upon recognition of a cluster of patients with a specific disease or
presentation with unusual symptoms. The VA Medical Center has an ongoing
active Infection Control surveillance system in place that is based on
the multidisciplinary interactions of the Infection Control office,
clinical providers and Pathology and Laboratory Medicine Service. This
system monitors for CDC reportable pathogens at all times using the
Passive Surveillance plan (see Attachment B). In times of increased risk
(as occurs each year with the Influenza Virus infection), the
surveillance plan transitions into Active Surveillance with closer
scrutiny and monitoring of potential infectious disease patients
entering our healthcare system. During times of increased risk for a
biologic event, the Medical Center utilizes the Active Surveillance plan
(see Attachment B).

Bioterrorism may also occur as an announced event, in which the
terrorist claims responsibility for dissemination of a pathogen and the
public is told an exposure has occurred (see Attachment C). These are
considered announced events, and must be considered as a real threat
unless proven to be a hoax. A number of announced bioterrorism events
occurred in the United States during 1998-2000, but these were
determined to have been hoaxes; that is, there were no true exposures to
the announced bioterrorism agents. The terrorist attacks of September
and October 2001, with the spread of concentrated anthrax spores through
the United States Postal system, have substantiated the need to have an
effective hospital response plan. If an Announced Event occurs in the
immediate local community area, the state Department of Public Health,
the police or the FBI field officer will most likely forward this
information to the VA Medical Center. Information coming from the
outside will always be treated as real, unless notification from proper
medical and/or legal authorities declare the incidents a hoax. The
possibility of a bioterrorism event will be ruled-out or ruled-in with
the assistance of the FBI, the state Department of Public Health and the
Clinical Microbiology Laboratory via the Laboratory Response Network.

5.2.8.2. *CDC-Defined Nationally Reportable Pathogens*. A notifiable
disease is one for which regular, frequent and timely information
regarding individual cases is considered necessary for the prevention
and control of the disease. A listing of infectious diseases designated
as reportable pathogens at the national level are noted below in Table
5-2.1.

In 1878, Congress authorized the U.S. Marine Hospital Service (the
forerunner of the Public Health Service) to collect morbidity reports
regarding cholera, smallpox, plague and yellow fever from U.S. overseas
consuls. The intention was to use this information to institute
quarantine measures to prevent the introduction and spread of these
diseases into the United States. This list of clinically important
reportable pathogens has continued to grow and in 1961, the CDC assumed
responsibility for the collection and publication of data concerning
nationally notifiable diseases. The list of nationally notifiable
diseases is revised periodically. Emerging diseases, such as West Nile
Virus, may be added while others with a decreasing national incidence
may be deleted. Public health officials at state health departments and
CDC continue to collaborate in determining which diseases should be
nationally notifiable, and states have the ability to modify the listing
for their geographic area. Although disease reporting is mandated by
legislation or regulation at the state and local levels, state reporting
to CDC is voluntary. Thus, the list of diseases considered notifiable
varies slightly by state. All states generally report the diseases that
the international community considers worthy of quarantine measures
(i.e., cholera, plague and yellow fever) in compliance with the World
Health Organization's International Health Regulations.

  -------------------------- --------------------- -----------------------
  **Table 5-2.1 - Nationally                       
  Reportable Pathogens                             
  List**                                           

  AIDS                       Giardiasis            Psittacosis

  Anthrax                    Gonorrhea             Q fever

  Botulism                   Haemophilus           Rabies, animal
                             influenzae (invasive) 

  Brucellosis                Hansen disease        Rabies, human
                             (M.leprae)            

  Chancroid                  Hantavirus pulmonary  Rocky Mountain Spotted
                             syndrome              Fever

  Chlamydia trachomatis      Hemolytic uremic      Rubella (adult and
  (genital infection)        syndrome              congenital syndrome)

  Cholera                    Hepatitis A, acute    Salmonellosis

  Coccidiodomycosis          Hepatitis B, acute    Severe Acute
                                                   Respiratory Syndrome
                                                   (SARS)

  Cryptosporidiosis          Hepatitis B,          Shigellosis
                             perinatal             

  Cyclosporiasis             HIV (Adult \>13 yrs)  Streptococcus Group A,
                                                   invasive

  Diphtheria                 HIV (Pediatric \< 13  Streptococcal
                             yrs)                  pneumoniae, drug
                                                   resistant, invasive or
                                                   \< 5yrs old

  Ehrlichiosis (HME, HGE,    Legionella            Syphilis
  other)                                           

  Encephalitits, arboviral   Listeriosis           Tetanus
  group                                            

  California serogroup       Lyme disease          Toxic Shock Syndrome
                                                   (Staph or Strep)

  Eastern equine (EEE)       Malaria               Trichinosis

  Powassan                   Meningococcal disease Tuberculosis

  St. Louis                  Mumps                 Tularemia

  Western Equine (WEE)       Pertussis             Typhoid fever

  West Nile Virus            Plague                Varicella deaths

  Enterohemorrhagic E. coli  Poliomyelitis,        Yellow fever
                             paralytic             
  -------------------------- --------------------- -----------------------

5.2.8.3. *Passive Surveillance* (see Attachment B, left side of chart).
A normal part of clinical microbiology laboratory and infection control
operations is to constantly monitor for potential reportable diseases
and for diseases that require implementation of a higher level of
personal protective equipment, contact isolation and/or respiratory
isolation. Patient care teams evaluate patients and order cultures and
serologic studies based on clinical history, signs and symptoms. These
cultures are forwarded in a timely fashion to the clinical microbiology
laboratories for direct specimen evaluation (gram stains, KOH
preparations, acid-fast stains) and plating onto the most appropriate
medias, culture, identification and sensitivity testing. Laboratories
maintain a safe working environment, working with all patient specimens
as unknown potentially deadly pathogens. Clinical microbiology
laboratories at the VA Medical Center must ensure compliance with
College of American Pathology (CAP), JCAHO, Office of the Inspector
General (OIG), Food and Drug Administration (FDA) and CDC standards.
Routine microbiology operations are conducted at Biosafety Level 2,
while laboratory activities with known or high probability high-risk
respiratory pathogens such as *Mycobacterium tuberculosis* are conducted
at the Biosafety Level 3. Biosecurity in the clinical microbiology
laboratory is maintained in compliance with the Inspector General
guidelines as outlined in the Laboratory Biosafety and Biosecurity
Handbook 1106.2 (July 2004). For hospitals that do not have access to a
Biosafety level 3 (BSL3) facility or during times that the BSL3 is
temporarily out of service or inoperable, specimens should be forwarded
to the Public Health Service laboratory as outlined in the Laboratory
Response Network.

If a public health system-defined reportable pathogen is definitively
identified, both the patient care team and the infection control team
are notified; and this information is then forwarded through the
Director's office to the Public Health Service. If pathogens are
identified that are not defined as reportable, only the patient care
teams are notified of the results. All reportable cases are aggregated
on a monthly basis, and reported by the Infection Control team, through
the Infection Control Committee to the hospital Director's office. The
Public Health Service (local and/or state) forwards reportable pathogens
submitted by all regional hospitals to the Centers for Disease Control
(CDC) and Prevention in Atlanta, Georgia, for U.S.-wide aggregation of
epidemiologic data. This reporting to the CDC during the passive
surveillance period occurs on a routine periodic timeline (weekly,
monthly, etc.).

5.2.8.4. *Active Surveillance* (Attachment B, right side of chart).
During a period of increased risk for a biologic event or outbreak, such
as that occurring annually during the usual winter influenza virus
season, the VA Medical Center operates at an increased level of biologic
surveillance; this is referred to as Active Surveillance. Other
situations that may require implementation of active surveillance
include any announcement or report of a specific biologic event coming
from the Public Health Services, local authorities, other community
hospitals, local emergency agencies or federal authorities, such as the
FBI, CDC or VA Central Office (VACO). During any period of active
surveillance, all previous precautions as outlined under passive
surveillance are maintained. In addition, there is a higher level of
clinical suspicion and closer monitoring at both the clinical care level
(with daily review of emergency department and/or acute care clinics)
and the clinical microbiology and/or serology level. The notification
process during active surveillance may begin with a suspect pathogen
isolate or presumptive identification with follow-up confirmation
performed at the state health department laboratory/laboratory response
network. Both the clinical care teams and the infection control teams
will follow suspect clinical presentations as a joint effort. Suspect
presentation may include, but is not limited to, one of the following:

-   Acute pulmonary syndrome with fever.

-   Viral exanthemas (pustular or hemorrhagic).

-   Bulbar or Respiratory palsy.

-   Acute unexplained gastroenteritis.

-   Hemorrhagic diathesis with fever.

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-   Acute hepatitis with fever.

Reporting during the active surveillance occurs on an ongoing basis
throughout the day to the Infection Control team and the Director's
Office. There may be a need to implement a rapid testing method (such as
a rapid influenza antigen tests) for use during both daytime and evening
shifts in order to facilitate rapid disease specific therapeutic steps.
Reporting to the Public Health Service also occurs in an expedited
fashion. If needed, the Director will activate the Incident Command
System.

5.2.8.5. *Syndrome-Based Criteria*. Rapid response to a
bioterrorism-related outbreak requires prompt identification of its
onset. Because of the rapid progression to illness and potential for
dissemination of some of these agents, it may not be practical to await
diagnostic laboratory confirmation. Instead, it may be necessary to
initiate a response based on the recognition of high-risk syndromes.
Table 5-2.2 below serves as a quick reference to consider for potential
clinical syndromes and potential biologic agents, if dealing with a
potential bioterrorism or naturally occurring outbreak of unknown
origin.

###### Table 5-2.2 - Clinical Syndromes in the Bioterrorism Event

+------------------------------------+---------------------------------+
| Syndrome                           | Potential Agents to Consider    |
+------------------------------------+---------------------------------+
| Acute Respiratory Syndrome with    | Anthrax, inhalation             |
| Fever                              |                                 |
|                                    | Blastomycosis                   |
|                                    |                                 |
|                                    | Coccidiodomycosis               |
|                                    |                                 |
|                                    | Glanders (*Burkholderia         |
|                                    | mallei*)                        |
|                                    |                                 |
|                                    | Hantavirus                      |
|                                    |                                 |
|                                    | Histoplasmosis (acute heavy     |
|                                    | infection)                      |
|                                    |                                 |
|                                    | Legionella (Legionnaires        |
|                                    | Disease)                        |
|                                    |                                 |
|                                    | Leptospirosis                   |
|                                    |                                 |
|                                    | Melioidosis                     |
|                                    |                                 |
|                                    | Plague, pneumonic type          |
+------------------------------------+---------------------------------+
| Acute Respiratory Syndrome without | T2 Mycotoxin ('yellow rain')    |
| Fever                              |                                 |
+------------------------------------+---------------------------------+
| Fever with prominent joint and     | Blastomycosis                   |
| muscle pain                        |                                 |
|                                    | Brucellosis                     |
|                                    |                                 |
|                                    | Coccidiodomycosis               |
|                                    |                                 |
|                                    | Alphavirus infection            |
|                                    |                                 |
|                                    | Flavivirus infection (e.g.      |
|                                    | Dengue fever)                   |
+------------------------------------+---------------------------------+
| Acute Hepatitis Syndrome and fever | Aflatoxins                      |
|                                    |                                 |
|                                    | Ebola and Marburg               |
|                                    |                                 |
|                                    | Flavivirus infection (e.g.      |
|                                    | Dengue fever)                   |
|                                    |                                 |
|                                    | Leptospirosis                   |
|                                    |                                 |
|                                    | Q fever                         |
|                                    |                                 |
|                                    | Ricin                           |
|                                    |                                 |
|                                    | Rift Valley Fever               |
|                                    | (Bunyaviridae)                  |
+------------------------------------+---------------------------------+
| Hemorrhagic Syndrome with fever    | Aflatoxins                      |
|                                    |                                 |
|                                    | Alphavirus infection            |
|                                    |                                 |
|                                    | Ebola and Marburg               |
|                                    |                                 |
|                                    | Flavivirus infection (e.g.      |
|                                    | Dengue fever)                   |
|                                    |                                 |
|                                    | Hantavirus (Sin Nombre virus;   |
|                                    | Hantavirus Pulmonary            |
|                                    | Hemorrhagic Syndrome)           |
|                                    |                                 |
|                                    | Lassa virus (Arenavirus group)  |
|                                    |                                 |
|                                    | Leptospirosis                   |
|                                    |                                 |
|                                    | Q fever                         |
|                                    |                                 |
|                                    | Ricin                           |
|                                    |                                 |
|                                    | Rift Valley Fever               |
|                                    | (Bunyaviridae)                  |
+------------------------------------+---------------------------------+
| Prominent Hilar Adenopathy with    | Anthrax (particularly if there  |
| fever                              | is prominent widened            |
|                                    | mediastinum                     |
|                                    | [without]{.underline}           |
|                                    | pneumonia; may or may not have  |
|                                    | CNS symptoms)                   |
|                                    |                                 |
|                                    | Blastomycosis                   |
|                                    |                                 |
|                                    | Brucellosis                     |
|                                    |                                 |
|                                    | Coccidiodomycosis               |
|                                    |                                 |
|                                    | Tularemia, pneumonic form       |
+------------------------------------+---------------------------------+
| Petechial rash and fever           | Flavivirus (e.g. Dengue fever)  |
|                                    |                                 |
|                                    | Hantavirus (usually with renal  |
|                                    | failure)                        |
|                                    |                                 |
|                                    | Ehrlichiosis                    |
|                                    |                                 |
|                                    | Lassa virus                     |
|                                    |                                 |
|                                    | Rocky Mountain Spotted Fever    |
|                                    |                                 |
|                                    | Typhus                          |
|                                    |                                 |
|                                    | Yellow Fever                    |
+------------------------------------+---------------------------------+
| Cutaneous papules, macules or      | Anthrax (cutaneous anthrax may  |
| ulcerations with fever             | mimic the brown recluse spider  |
|                                    | bite!)                          |
|                                    |                                 |
|                                    | Blastomycosis                   |
|                                    |                                 |
|                                    | Coccidiodomycosis               |
|                                    |                                 |
|                                    | Histoplasmosis                  |
|                                    |                                 |
|                                    | Monkeypox (clinically identical |
|                                    | to Smallpox, but milder disease |
|                                    | and fewer lesions)              |
|                                    |                                 |
|                                    | Plague (bubonic form)           |
|                                    |                                 |
|                                    | Scrub Typhus                    |
|                                    |                                 |
|                                    | Smallpox (classic form)         |
|                                    |                                 |
|                                    | Tuberculosis                    |
|                                    |                                 |
|                                    | Tularemia, ulceroglandular form |
+------------------------------------+---------------------------------+

Each of the agent-specific plans (see sample SOPs in Section 6.2.3.1.)
includes a syndrome description (i.e., typical combination of clinical
features of the illness at presentation) that should alert healthcare
practitioners to the possibility of a bioterrorism-related outbreak. In
addition, the most likely suspected clinical syndromes are outlined in
the VAMC Biologic Surveillance Plan under the Active Surveillance. The
VA Medical Center Biologic Surveillance Plan outlining both the Passive
Surveillance and the Active Surveillance (Attachments B) are in
flow-diagram forms that may be helpful as a quick reference or for
posting in the clinical care areas of the facility.

5.2.8.6. *Epidemiologic Features*. Epidemiologic principles must be used
to assess whether a patient's presentation is typical of an endemic
disease, or is an unusual event that should raise concern. Features that
should alert healthcare providers to the possibility of a
bioterrorism-related outbreak include:

-   A rapidly increasing disease incidence (e.g., within hours or days)
    in a normally healthy population.

-   An epidemic curve that rises and falls during a short period of
    time.

-   An unusual increase in the number of people seeking care, especially
    with fever, respiratory or gastrointestinal complaints.

-   An endemic disease rapidly emerging at an uncharacteristic time or
    in an unusual pattern.

-   Lower attack rates among people who have been indoors (or out of the
    environmentally contaminated zone) compared with people who have
    been outdoors (or in the environmentally contaminated zone).

-   Clusters of patients arriving from a single locale.

-   Large numbers of rapidly fatal cases.

-   Any patient presenting with a disease that is relatively uncommon
    and has bioterrorism potential (e.g., pulmonary anthrax, tularemia
    or plague).

-   Unusual numbers of animal deaths reported by veterinarians and/or
    Public Health Services.

-   Unusual numbers of deaths with similar features occurring in the
    immuno-compromised population.

5.2.9. ***Special Considerations for Mission Critical Engineering
Systems***. In the setting of an intentional bioterrorism event or a
pandemic respiratory outbreak, it is essential to involve facility
Engineering personnel in the patient management planning processes in
order to ensure maintenance of a safe facility environment for both
hospital personnel and our patients. Areas within the expertise of
Engineering that must be included in the planning process include:

-   Heating, Ventilation and Air-Conditioning (HVAC) System Management.

-   Steam Distribution Systems.

-   Room and Hood Exhaust Integrity.

-   Water Delivery Systems.

-   Water Conditioning/Drinkability.

-   Critical Supplies and Equipment Resources.

-   Transportation Systems (Pneumatic tubes, elevators, robotic systems,
    food service transportation needs).

-   Medical Gases Maintenance.

Involving Engineering in the planning and disaster management process
will ensure that mission critical engineering systems essential to
maintaining facility integrity will be properly monitored and preserved.
Attachment D provides a facility-wide list of potential mission critical
systems impacts for the clinical team and the engineering team to
consider.

5.2.10. ***Infection Control Practices for Patient Management***. The
management of patients following suspected or confirmed biologic events
must be well organized and rehearsed. Strong leadership and effective
communication are paramount. There is often more planning time in the
naturally evolving biologic event, particularly if they are predictable
seasonal events, such as the yearly influenza outbreaks; and these can
be used to test the system for a more devastating event, such as an
influenza pandemic, SARS outbreak or intentional bioterrorism event.

> A recent program initiated by the VA system wide is the "Don't Pass It
> On" campaign. The purpose of this program is to make all healthcare
> staff aware of how organisms are passed from person to person, and the
> most effective methods for ensuring that employees take appropriate
> prevention measures. Implementing this program is one method to
> mitigate to potential for spread of healthcare transmitted infections.
> This program was developed based on CDC hand and respiratory hygiene
> plan. (Link to VA program
> <http://vaww.vhaco.va.gov/phshcg/InfectionDontPassItOn/Default.htm>.)

5.2.10.1. *Isolation and Standard Precautions*. Many agents of biologic
events are not transmitted through the respiratory system from person to
person; re-aerosolization of these agents is difficult. Person-to-person
contact transmission is always a concern, even with commonly encountered
pathogens. For this reason, all patients in healthcare facilities,
including symptomatic patients with suspected or confirmed biologic
event-related illnesses, should be managed utilizing Standard
(Universal) Precautions with the appropriate personal protection
equipment (PPE). Standard Precautions are designed to reduce
transmission from both recognized and unrecognized sources of infection
in healthcare facilities, and are recommended for all patients receiving
care, regardless of their diagnosis or presumed infection status. Using
Standard Precautions with all patient encounters provides a consistent
standardized level of protection for hospital personnel; it is just good
common sense! For certain diseases or syndromes (e.g., SARS, pandemic
influenza, avian flu, smallpox and pneumonic plague), additional
respiratory precautions are needed to reduce the likelihood for
person-to-person respiratory transmission. See sample Standard Operating
Procedures (SOPs), Section 6.2.3.1.4, for specific diseases and
requirements for additional isolation precautions.

Effective use of Standard Precautions measures prevents direct contact
with all body fluids (including blood), secretions, excretions,
non-intact skin (including rashes) and mucous membranes. Standard (or
universal) precautions routinely practiced by healthcare providers
include handwashing, gloves, face protection and gowns/lab coats.

5.2.10.2. *Handwashing*. Hands are washed after touching blood, body
fluids, excretions, secretions or items contaminated with such body
fluids, whether or not gloves are worn. Hands are washed immediately
after gloves are removed, between patient contacts and as appropriate to
avoid transfer of microorganisms to other patients and the environment.
Plain soap, antimicrobial-containing soaps or antimicrobial antiseptic
foams may be used according to facility policy and procedures. Thorough
handwashing with plenty of soap and water for a period of 15-30 seconds
is a simple, but very effective safety measure that should be used by
all hospital personnel with direct patient care. Contact infection
control with any questions or concerns regarding appropriate steps for
Standard Precautions. Remember your annual mandatory refresher education
module for Infection Control!

5.2.10.3. *Gloves*. Clean, non-sterile gloves are worn when touching
blood, body fluids, excretions, secretions or items contaminated with
such body fluids. Clean gloves are put on just before touching mucous
membranes and non-intact skin. Gloves are changed between tasks and
between procedures on the same patient, if contact occurs with
contaminated material. Hands are washed promptly after removing gloves
and before leaving a patient care area. Gloves should always be changed
before attending to another patient.

5.2.10.4. *Gowns*. An impervious gown or lab coat is worn to protect
skin and prevent soiling of clothing during procedures and patient care
activities that are likely to generate splashes or sprays of blood, body
fluids, excretions or secretions. Selection of gowns and gown materials
should be suitable for the activity and amount of body fluid likely to
be encountered. Soiled gowns are removed promptly, and hands are washed
to avoid transfer of microorganisms to other patients and environments.
Disposable gowns should be discarded into appropriate contaminated waste
containers. Laundered gowns and lab-coats should be placed in
appropriate contaminated linen containers. All waste containers should
be clearly and appropriately labeled to avoid the need for manual
sorting by personnel within the Environmental Management Service.

5.2.10.5. *Face Protection*. Standard precaution face protection is
achieved by simply wearing a regular surgical mask or face shield to
protect staff from fomite respiratory droplets and body fluid splashes.
Face protection should be used anytime there is a risk of body fluid,
blood or secretions contact or splashes. Safety goggles should be
considered when eye protection is needed.

5.2.10.6. *Respiratory Protection*. Should there be a concern about
respiratory agent transmission (e.g., pandemic flu, SARS, tuberculosis),
all hospital personnel with patient contact should use appropriate
respiratory protection as recommended by the CDC and APIC \[e.g., N95
masks, N100 (HEPA) masks, tight-fitting facepiece masks with HEPA filter
cartridges or a hooded system with HEPA filter cartridges.\] Active
fit-testing programs and medical clearance procedures are essential
components of all hospital respiratory protection programs.

5.2.10.7. *Patient Placement*. In small-scale events, routine facility
patient placement and infection control practices should be followed.
However, when the number of patients presenting to the facility is too
large to allow routine triage and isolation strategies, it may be
necessary to apply practical alternatives and initial use of designated
alternate sites for patient care within or outside the Medical Center.
These may include cohorting/grouping patients who present with similar
syndromes, i.e., grouping affected patients into a designated section of
a clinic or emergency department, a designated ward or floor of the
facility, or even setting up a response center at a separate building.
Designated cohorting/grouping sites should be chosen in advance by the
executive Emergency Management Planning Committee in consultation with
facility Engineering staff based on patterns of airflow and ventilation,
availability of adequate plumbing and waste disposal, and capacity to
safely hold potentially large numbers of patients. The triage or cohort
site will have a controlled entry to minimize the possibility for
transmission to other patients at the facility and to staff members not
directly involved in managing the outbreak. At the same time, reasonable
access to vital diagnostic services, e.g., Radiology and Respiratory
Therapy Departments, will be maintained. The sites will be announced at
the time of implementation of the plan and will be determined by the
suspected causative organism of the attack and the projected number of
patients to be managed.

5.2.10.8. *Respiratory Isolation*. Most hospitals have respiratory
isolation rooms with appropriate negative air flow capability for a
limited number of patients. These are primarily in place for the safe
management of patients with tuberculosis. In the event of a
person-to-person transmittable outbreak, there may be the need to
increase hospital capability to safely manage these patients.
Consideration will be given to developing patient cohort groups to allow
grouping of patients into negative airflow respiratory isolation rooms.
Pre-planning steps for VA Medical Centers include the ability for
Engineering and Safety to work together rapidly to implement the use of
portable negative air units capable of converting pre-designated rooms
with a window to the outside into additional respiratory isolation
rooms. Before any patients are placed in these expanded rooms, the
airflow conditions must be tested and validated by the facility Safety
Officer.

5.2.10.9. *Patient Transport*. Patient transport requirements for
specific potential biologic agent events are addressed within specific
SOPs (see Section 6.2.3.1.). In general, the transport and movement of
patients with biologic event-related infections, such as for patients
with any epidemiologically important infection (tuberculosis,
chickenpox, measles, influenza, SARS, etc.), should be limited to
movement that is essential for providing care to the patient. The
patient and staff must wear appropriate level masks while the patient is
being transported. This will reduce the opportunity for transmission of
microorganisms within the healthcare facility. If large numbers of
patients are anticipated and transportation to essential diagnostic
procedures is anticipated, pre-designated transport routes with limited
designated elevators should be used. It is critical to involve
Engineering Service in these plans and decisions, so that intricate
details of exhaust and HVAC zones can be appropriately considered.

5.2.10.10. *Cleaning, Disinfection and Sterilization of Equipment and
Environment*. Principles of Standard Precautions should be generally
applied for the management of patient care equipment and environmental
control. The facility will follow safe routine protocols for cleaning
and disinfection of environmental surfaces, beds, bedrails, bedside
equipment and other frequently-touched surfaces and equipment.
Facility-approved disinfectants and germicidal cleaning agents should be
available in patient care areas to use for cleaning spills of
contaminated material and disinfecting non-critical equipment. Used
patient-care equipment that is soiled or potentially contaminated with
blood, body fluids, secretions or excretions should be handled in a
manner that prevents exposures to skin and mucous membranes, avoids
contamination of clothing and minimizes the likelihood of transfer of
microbes to other patients and environmental surfaces. Reusable
equipment is not used for the care of another patient until it has been
appropriately cleaned and reprocessed. Ensure that single-use patient
items are appropriately discarded. Sterilization is required for all
instruments or equipment that enter normally sterile tissues or through
which blood flows. Rooms and bedside equipment of patients with
bioterrorism-related infections should be cleaned using the same
procedures that are used for all patients as a component of Standard
Precautions, unless the infecting microorganism and the amount of
environmental contamination indicates the need for special cleaning. In
addition to adequate cleaning, thorough disinfection of bedside
equipment and environmental surfaces may be indicated for certain
organisms that can survive in the inanimate environment for extended
periods of time. The methods and frequency of cleaning and the products
used are determined by facility policy. Patient linen should be handled
in accordance with Standard Precautions. Although linen may be
contaminated, the risk of disease transmission is negligible if it is
handled, transported and laundered in a manner that avoids transfer of
microorganisms to other patients, personnel and environments.
Contaminated waste and linens must be disposed of into appropriately
labeled, pre-designated containers to avoid the need for any manual
sorting of these materials in accordance with the facility's Exposure
Control Plan (see the facility Infection Control Manual).

5.2.10.11. *Discharge Management*. Ideally, patients with biologic
event-related infections will not be discharged from the facility until
they are deemed non-infectious, stable and able to care for themselves.
Home-care instructions will be distributed to affected individuals in
the event that large numbers of persons exposed may preclude admission
of all infected patients. Depending on the exposure and illness,
home-care instructions may include recommendations for the use of
appropriate barrier precautions, handwashing, waste management and
cleaning and disinfection of the environment and patient care items.
Phone contact numbers will be provided to all discharged and/or released
patients, so that they may call back to the VA Medical Center with any
additional concerns or questions.

5.2.11. ***Post Exposure Management***.

5.2.11.1. *Decontamination of Patients and Environment*. Actual
decontamination for a biological event should only be needed in
instances of gross contamination. Decisions regarding the need for
decontamination should be made in consultation with the Infection
Control team and hospital Safety Officer. The need for decontamination
or removal of possible pathogens depends on the suspected exposure, and
in most cases will not be necessary. The goal of decontamination after
exposure to a biologic agent is to reduce the extent of gross external
contamination of the patient and to prevent spread within the Medical
Center. Biological decontamination or self-showering of exposed
individuals prior to receiving them in the healthcare facility may be
necessary to ensure the safety of patients and staff while providing
care. If an announced biologic terrorist event with gross contamination
occurs, facilities for self-showering of affected individuals, bagging
of clothes and distribution of hospital clothing will be set up outside
of the Emergency Department within the external decontamination
facility.

In an event in which patients are grossly contaminated with an unknown
substance that may be biologic, standard hospital receiver
decontamination protocols should be implemented. Any unknown substance
gross contamination could potentially represent a biologic agent,
chemical agent with delayed symptoms or radiological agent. Potentially
harmful practices, such as bathing patients with bleach solutions, are
unnecessary and should be avoided. Clean water, saline solution or
commercial ophthalmic solutions are recommended for rinsing eyes. VAMC
personnel will be stationed at both the male and female shower sites to
assist in any way, and to ensure that showering proceeds in an organized
calm fashion. Designated VAMC employees will escort all patients who
have showered and changed to a large secure designated waiting area.
(See sample Healthcare First Receiver Decontamination Readiness Plan,
Part 1 of this Section; and sample Healthcare First Receiver
Decontamination SOP, Section 6.3.3.2, for more details.) The FBI may
require collection of exposed clothing and other potential evidence for
submission to FBI or Department of Defense laboratories to assist in
exposure investigations. (See sample Chain of Custody Readiness Plan,
Section 5, Part 6A.)

5.2.11.2. *Prophylaxis and Post-Exposure Immunization*. Recommendations
for prophylaxis are subject to change. Current recommendations for
post-exposure prophylaxis and immunization are provided in specific SOPs
for relevant potential biologic agents. Up-to-date recommendations
should be obtained in consultation with local and state health
departments and CDC during any emergency or disaster setting. Facilities
should ensure that policies are in place to identify and manage hospital
personnel exposed to infectious patients. Careful documentation of
potential exposures must be maintained, and employees should be
encouraged to complete appropriate workplace exposure documentation
forms (e.g., CA-1 and CA-2 forms). In general, maintenance of accurate
occupational health records will facilitate identification, contact,
assessment and delivery of post-exposure care to potentially-exposed
healthcare workers. Coordination between Infection Control and Employee
Health services, as well as effective employee communication, is
essential to maintain awareness and minimize panic.

5.2.11.3. *Triage and Management of Large Scale Exposures and Suspected
Exposures*. In the event of a large-scale exposure, processes for
triage, safe housing and medical care for potentially large numbers of
affected individuals will follow the Emergency Preparedness mass
casualty plan. Triage and management planning for large-scale events may
include:

-   Establishing networks of communication and lines of authority;
    coordinating on-site care.

-   Establishing networks of communication internally to provide
    continuous staff education and status reports, and to maximize
    education while minimizing rumor, fear and panic.

-   Planning for cancellation of non-emergency services and procedures.

-   Planning with Nutrition and Food Service for anticipated needs
    during biologic event.

-   Planning with Environmental Management Services to ensure
    appropriate Environmental Management staff are educated and aware of
    procedures to be followed during a biologic event to ensure their
    safety.

-   Identifying sources able to supply available vaccines, immune
    globulin, antibiotics and anti-toxin (with assistance from local and
    state public health departments).

-   Planning for the efficient evaluation and discharge of patients.

-   Developing discharge instructions for patients determined to be
    non-contagious or in need of additional on-site care, including
    details regarding if and when they should return for care or if they
    should seek medical follow-up.

-   Determining availability and sources for additional medical
    equipment and supplies (e.g., ventilators) that may be needed for
    urgent large-scale care.

-   Planning for the allocation or re-allocation of scarce equipment in
    the event of a large-scale event (e.g., duration of ventilator
    support of terminally afflicted individuals).

-   Coordinating with Pathology service; identifying the institution's
    ability to manage a sudden increase in the number of cadavers on
    site.

5.2.11.4. *Psychological Aspects of Bioterrorism*. Following a biologic
event, fear and panic can be expected from patients, hospital personnel
and members of the community. Psychological responses following a
biologic event may include horror, anger, panic, unrealistic concerns
about infection, fear of contagion, paranoia, social isolation and
demoralization. Infection Control professionals have developed prior
working relationships with the Emergency Medical Response Team and
Mental Health support personnel (e.g., psychiatrists, psychologists,
social workers, clergy and volunteer groups), and will assist in
collaboration efforts to address the immediate and subsequent mental
health needs of the patients, hospital personnel and family members. The
hospital Director and Public Affairs Officer or their designees will
coordinate with the media. The Emergency Operations Center and medical
officer(s) will coordinate with external Emergency Medical Services. VA
Medical Centers should have an active Emergency Medical Response Team
(EMRT) composed of volunteer hospital personnel with specialized
training to deal with the emotional well-being of patients, patient
family members and staff involved in a disaster of this type. Local,
state and federal experts may also provide assistance with
communications and education needs.

When developing this plan, consideration of the following was made to
address *patient and general public* fears:

-   Minimize panic by clearly explaining risks, offering careful but
    rapid medical evaluation/treatment, and avoiding unnecessary
    isolation or quarantine.

-   Treat anxiety in unexposed persons who are experiencing somatic
    symptoms (e.g., with reassurance, or diazepam-like anxiolytics as
    indicated for acute relief of those who do not respond to
    reassurance).

When developing this plan, consideration of the following was made to
address *healthcare worker* fears:

-   Provide bioterrorism readiness education, including frank
    discussions of potential risks and plans for protecting healthcare
    providers.

-   Invite active voluntary involvement in the biologic event and
    terrorism readiness planning process.

-   Encourage participation in disaster drills.

-   Fearful or anxious healthcare workers may benefit from their usual
    sources of social support or by being asked to fulfill a useful role
    (e.g., as a volunteer at the triage site).

5.2.12. ***Laboratory Support and Confirmation***. VA Medical Center
Pathology and Laboratory Medicine Services have clinical microbiology
laboratories certified to handle Biohazard level 2 and 3 organisms. VA
clinical laboratory facilities participate in both CAP and CDC surveys
that include identification of unknowns representing numerous biologic
pathogens. Some laboratories also participates as a member of the CDC
Laboratory Response Network and participates in Bioterrorism Proficiency
Surveys. Identification or presumptive identification of any reportable
pathogen, as outlined by the CDC, mandates immediate notification of the
Infection Control office that in turn notifies the State Department of
Public Health. In the event of an isolated potential bioterrorism agent,
the specimen will be packaged in accordance with Department of
Transportation (DOT) guidelines for shipping of biohazardous materials
and delivered to the state Department of Public Health Microbiology
Laboratory, or the appropriate designated Laboratory Response Network
Laboratory. The VA Medical Center will work with county, state and
federal Public Health Service representatives to tailor diagnostic
strategies to specific events. Currently the Bioterrorism Emergency
Number at CDC is at the Emergency Response Office, National Center for
Environmental Health (NCEH), 770-488-7100.

5.2.12.1. *Obtaining Diagnostic Samples*. See specific recommendations
for diagnostic sampling for each agent within the SOP section (Section
6.2.3.1.). Sample collection should be performed in accordance with
Standard Precautions, using increased respiratory protection as needed,
based on the event and symptoms encountered. In all cases of suspected
bioterrorism, collect an acute phase serum sample to be analyzed,
aliquotted and saved for comparison to a later convalescent serum
sample. The CDC website for Laboratory Protocols and the Laboratory
Response Network Guidebook is helpful when dealing with specific agents
or syndromes. See sample Chain of Custody guidelines (Section 5, Part 6,
Special Considerations) to ensure compliance with chain-of-custody
requirements from the point of specimen collection. The Laboratory
Response Network guidebook, provided by the Public Health Service
Laboratory to each local hospital, also includes shipping information
and a PHS Chain-of-Custody form for all samples submitted for evaluation
during a bioterrorism event.

5.2.12.2. *Laboratory Level for Handling Biologic Agents*. To evaluate
laboratory capacity in the United States, laboratories are grouped into
one of four levels, according to their ability to support diagnostic
needs. This VAMC laboratory operates at the Bio Safety level (BSL) 2 in
the routine clinical microbiology laboratory. The BioSafety level (BSL)
3 clinical microbiology workload is performed (in-house/at a reference
laboratory).

5.2.12.3. *Transport Requirements*. Specimen packaging and transport
will be coordinated with local and state health departments, the
Laboratory Response Network and the FBI. Packaging materials and
transport media will be chosen by VAMC clinical laboratory in
collaboration these entities. For specific instructions, contact the
Bioterrorism Emergency Number at the CDC Emergency Response Office
(770-488-7100) or the state Public Health Laboratory, Bioterrorism
Preparedness Coordinator [\_\_\_\_\_\_(name)\_\_\_\_\_\_\_]{.underline}
at [\_\_\_\_(number)\_\_\_\_]{.underline}.

5.2.12.4. *CDC Laboratory Response Network*. The Centers for Disease
Control and Prevention established the Laboratory Response Network (LRN)
per Presidential Decision Directive 39, 1995. This Directive outlined
national anti-terrorism policies, and assigned specific missions to
federal departments and agencies. Through a collaborative effort
involving LRN founding partners, the Federal Bureau of Investigation and
the Association of Public Health Laboratories, the LRN became
operational in August 1999. Its objective was to ensure an effective
laboratory response to bioterrorism by helping to improve the nation's
public health laboratory infrastructure, which had limited ability to
respond to bioterrorism.

Today, the LRN is charged with the task of maintaining an integrated
network of local public health, federal, military and international
laboratories that can respond to both bioterrorism and chemical
terrorism. The LRN is a unique asset in the nation's growing
preparedness for biological and chemical terrorism. The linking of state
and local public health laboratories, veterinary, agriculture, military
and water-and food-testing laboratories is unprecedented.

The Laboratory Response Network (LRN) and its partners will maintain an
integrated national and international network of laboratories that are
fully equipped to respond quickly to acts of chemical or biological
terrorism, emerging infectious diseases and other public health threats
and emergencies.

For laboratories participating as a member of the LRN, a separate LRN
procedure manual, including transportation supplies and chain-of-custody
forms, is maintained in both the Emergency Department and the Clinical
Microbiology Laboratory. In many states, state funding sources have
provided a mechanism for fax, email and electronic communication
directly to the State Public Health Laboratories through a dedicated T-1
line and computer system located in the Microbiology Laboratory. This
connectivity to the Public Health Service is linked directly to the
Emergency Operations Center location, Infection Control Office, Clinical
Laboratory, Engineering and Emergency Department/Internal Medicine.

5.2.12.5. *Tissue Handling and Post-Mortem Care*. Pathology and
Laboratory Medicine Service should be informed of any potentially
infectious outbreak prior to submitting specimens for examination.
Pathology and Laboratory Medicine Service will use standard infectious
case protocols for handling potentially infectious bodies and tissues.
VAMC has a separate autopsy room designated as an isolation room that
can be used for examination of patients who die from a potentially
infectious disease. In the event of a bioterrorist event resulting in
patient deaths, all post-mortem examinations will be coordinated with
the state Medical Examiner. In the event of a bioterrorist related
death, all tissues and reports become critical evidence, and will be
handled in accordance with state and federal law. Instructions will be
given to funeral directors as needed.

5.2.13. ***Patient, Visitor and Public Information***. Clear,
consistent, understandable information will be provided (e.g., via fact
sheets) to patients, visitors and the general public. During
biologic-related outbreaks, visitors may be strictly limited. The lines
of authority and flow of communication are outlined in the Biologic
Event Plan algorithm (Attachment B). Crowd control will be the
responsibility of VAMC Police and Security who may be assisted by VAMC
Emergency Medical Response Team (EMRT) members. Military personnel may
also be utilized in response to mass casualties, as designated by state
and federal leaders, and approved by the Department of Defense (DoD).

The Office and the Director and Public Affairs personnel will
disseminate information to the media. Failure to provide a public forum
for information exchange may increase anxiety and misunderstanding,
increasing fear among individuals who attribute non-specific symptoms to
exposure to the bioterrorism agent.

5.2.14. ***Standard Operating Procedures - Potential Agents***. Many
different bacteria, viruses, fungi and biologic materials such as toxins
may be encountered in a biologic outbreak or event. These may represent
a naturally occurring event, such as SARS or influenza virus outbreaks,
or an intentional bioterrorism release, either of which may compromise
the healthcare facility, patients, hospital personnel and the community.
Section 6.2.3.1. of this Guidebook includes sample standard operating
procedures (SOPs) for an initially unknown biologic agent entitled
Generic Biological Agent Event, as well as other specific biologic
events. Incorporated sample SOPs are listed below:

-   Generic Biological Agent Event (the Unknown Agent).

-   Anthrax Event in the Community or VA Medical Center.

-   Smallpox Event in the Community or VA Medical Center.

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-   Respiratory Virus Event (SARS or Pandemic Flu, etc.).

5.2.15. ***Drills and Exercises***. The reality of actually facing a
community-wide, region-wide or statewide biologic disaster is a daunting
consideration, regardless of whether it is a naturally occurring
phenomenon, such as the next anticipated aggressive influenza pandemic,
or an intentional bioterrorism release. The latter would, of course,
instill a greater degree of fear and urgency. No hospital expects to be
able to completely handle such an event without difficulty. The more
training and education provided, the more comfortable healthcare
providers feel about dealing with such an event.

Knowledge without practice is a fading process bound for inevitable
failure. It is important to utilize and exercise the bioterrorism
readiness plan using a progression of challenges. These may include
simple tabletop scenarios or full-scale drills. In order to ensure
constant readiness, drills and exercises should be performed often, and
must present increasingly challenging situations as expertise and
comfort levels rise. (See Section 9, Education, Training and Exercises.)
In any exercise plan, it is important to actually practice the things
that employees are least familiar with \-- things they don't do in their
day-to-day employment such as:

-   Consideration of Appropriate PPE levels for a specific biologic
    agent or event.

-   Collection and transport of patient samples.

-   Communication with Public Health Services and Laboratory Response
    Network.

After each drill, tabletop exercise or practice session, analyze:

-   What was done best?

-   What could have been done better?

-   What were the major problems?

-   What can we do to improve the process?

-   When can we next test our capabilities and try these improvements to
    see how well they actually work?

**Scenario 1:** You are working in the emergency department on the
weekend when you receive notification through the local public health
service that several confirmed cases of influenza virus have been
reported in your metropolitan area. During the evening shift, a
62-year-old gentleman presents with a 4-day history of fever, cough,
muscle and joint pain and generalized malaise. You suspect influenza
virus infection. What do you do?

Considerations:

-   You know the probable agent, and you deal with this type of
    naturally occurring outbreak each year.

-   Do you have rapid antigen testing capabilities and is it available
    24 hours a day?

-   How do you maintain safety of the facility while providing
    appropriate care?

-   What treatment and disposition recommendations would you make?

-   What reporting requirements should be invoked, and when?

**Scenario 2:** You have a report of a probable food borne outbreak
occurring at the nearby military base. The base uses your facility as a
resource for acute after-hours care. During the evening shift, you
receive 6 victims from the event, all presenting with severe nausea,
vomiting, diarrhea and dehydration. How would you handle the situation?

Considerations:

-   The number of victims is small and within the capability of staff on
    duty.

-   The possible agent's list is small and part of the work-up may
    include collection of samples for culture and/or toxin testing.

-   What triage and treatment decisions need to be made?

-   What reporting requirements should be invoked, and when?

**Scenario 3**: A curious illness has been reported in the adjacent
county by the public health service, notifications indicate that the
predominant symptoms are respiratory with flu-like features. Occasional
patients have been noted to be coughing up blood. No definitive culture
proven diagnosis has been established. All medical facilities in the
area have been alerted to watch for these types of patients and notify
the public health care immediately if these patients present to your
facility. A minimum of respiratory droplet precautions is being advised,
with recommendations to strongly consider use of N-95 masks or higher.
During the midnight shift, a total of 12 patients have presented to the
medical facility with identical symptoms of fever, cough, shortness of
breath and generalized weakness. Two are noted to have blood streaked
sputum.

Considerations:

-   The agent is unknown, but should be treated as potentially
    contagious by either the respiratory droplet or airborne routes.
    Health of the patients and healthcare workers must be considered.

-   What triage and treatment decisions should be made?

-   Specimens for routine, fungal, mycobacterial and viral cultures as
    well as an acute serum sample should be collected. What are the
    testing and/or shipping considerations in this setting?

-   What are the notification requirements and when should this occur?

**Scenario 4:** An open-air arena is packed with spectators attending a
rock concert when a plane flies overhead, releasing a fine clear
non-oily mist into the crowd. Immediate panic and disorder erupts with
spectators fleeing the scene and reporting to the nearest medical
facilities. Estimated attendance is 27,000. Of the 12 medical centers
within the metropolitan and surrounding areas, the VA Medical Center is
5 miles from the arena.

Considerations:

-   You may not be aware of the situation until patients begin arriving
    at the Medical Center. At best, you may only have 5 minutes to
    prepare. What are the most important initial steps? (Facility
    lock-down; emergency call back, etc.)

-   You don't know what the agent is. The possibilities include an
    infectious agent, chemical agent with delayed symptoms or water
    being used as a hoax. Do you need to deploy the decontamination
    team?

-   What notifications requirements does this scenario invoke and when
    should they occur?

-   What special hospital considerations come to mind? (e.g., triage,
    safety, detection devices, designated waiting areas, mental health
    and social services support staff, police perimeter control and
    crowd control.)

Attachments.

A. FBI Field Offices Contact Listing

B. Response Algorithm - Surveillance Plan (The Symptomatic Patient)

C. Response Algorithm - Biologic Event Plan

D. Mission Critical Engineering Systems Considerations

Section 5 - Part 3

Sample Radiological Event

And Terrorism Readiness Plan

5.3.1. ***Introduction***. The Radiation Event and Terrorism Readiness
Plan is a component of the VA Medical Center's Emergency Operations Plan
(EOP). The Plan is used for any radiological hazard situation,
accidental or intentional. The Plan is structured to operate under the
umbrella of the Incident Command System (ICS), implementing the Standard
Operating Procedures (SOPs) specific to radiological events. The Plan
provides an emergency response framework to protect the physical
infrastructure, employees and patients of the VA Medical Center (VAMC).

5.3.2. ***Purpose***. The purpose of the Radiation Event and Terrorism
Readiness Plan is to describe how the VA Medical Center responds to
radiological threats. The Plan identifies operating procedures and areas
of concern encountered for response to a radiological event. Specific
information and response protocols are detailed in the sample Standard
Operating Procedures SOPs) Section (Section 6).

5.3.3. ***Scope***. The Radiological Event and Terrorism Readiness Plan
applies to all employees and operates within the framework of Joint
Commission on Accreditation of Healthcare Organizations (JCAHO), Nuclear
Regulatory Commission (NRC), Occupational Safety and Health
Administration (OSHA), and Environmental Protection Association (EPA)
requirements.

5.3.4. ***Policy***. In the event of a radiological emergency, the ICS
Incident Commander will initiate the ICS. This ensures that the
necessary services and functions are provided to ensure a safe working
and patient care environment. The VA Medical Center will work closely
with community response agencies to achieve effective interaction during
response and recovery operations. The Radiological Event and Terrorism
Readiness Plan and associated SOPs facilitate the preparedness,
mitigation, response and recovery efforts needed to minimize any adverse
impact on the VA Medical Center.

5.3.5. ***Radioactive Material and Terrorist Events***. VA Medical
Centers must be adequately prepared to handle and treat victims exposed
radiation or contaminated with radioactive materials. Radiation exposure
or contamination that result in acute high radiation doses can occur in
the following scenarios: nuclear detonation, radiological dispersal
device, irradiation device or accident. The facility Health Physicist
(Radiation Safety Officer) is an indispensable resource when dealing
with radiation emergencies.

5.3.5.1. *Radiation Dispersal Device (RDD)*. A Radiological Dispersal
Device (RDD), or dirty bomb, uses conventional explosives in combination
with radioactive materials. The explosion causes the radioactive
material to be dispersed over a wide area, contaminating bystanders,
buildings, vehicles and anything in the blast radius. Due to the
dilution of the radioactive material being spread out over a wide area,
the health impact of the radiation itself is expected to be low, and not
result in a significant increase in potential health effects on a large
scale. Acute localized radiation injuries are possible if radioactive
materials such as cobalt-60, cesium-137, or strontium-90 are used in the
RDD. The main concern with an RDD is injuries from the blast (shrapnel
and static overpressure), psychological effects and environmental
contamination. The fear of radiation exposure could cause a mass panic
reaction among the general public, and the cost of environmental clean
up could be very high.

5.3.5.2. *Nuclear Detonation*. A nuclear detonation can produce
extremely high radiation dose rates during the first 60 seconds of the
blast and then from fission activation products in the form of fallout
near ground zero. Sources could be an Improvised Nuclear Device (IND),
backpack or suitcase device produced by one of the terrorist-sponsoring
countries or the former Soviet Union or a military weapon. This scenario
is least likely to occur compared to an RDD event or industrial accident
due to the difficulty in acquiring such a device.

5.3.5.3. *Irradiation Device*. An irradiation device is a container with
radioactive material that emits radiation and exposes individuals in
close proximity to the source. The individuals receive exposure to gamma
or beta radiation but are not contaminated themselves with radioactive
material. Accidents have occurred with radioactive sources used for
industrial radiography. A variety of health effects are possible,
depending on the activity of the source and the amount of time spent in
close proximity. Health effects can range from localized radiation
injuries to death.

5.3.6. ***Contamination and Exposure***. Radioactive contamination
occurs when radioactive material is deposited on or in an object or
person. Unlike chemical contaminants, radioactive material active enough
to constitute an exposure threat can be detected at great distances.
Gamma radiation (penetrating) can cause whole body irradiation; beta
emitters left on the skin can cause burns and scarring; and, alpha
emitters (non-penetrating) will not penetrate the intact epithelium. It
is highly improbable that a living patient would be so contaminated that
he or she would constitute a health hazard to responders.

5.3.6.1. *External Contamination*. External contamination is when
radioactive material comes into contact with a person's skin, hair or
clothing. The radioactive material can be in the form of a liquid, mixed
with dirt or dust or powder. The contamination is deposited on the
outside of the body.

5.3.6.2. *Internal Contamination*. Internal contamination occurs when
radioactive material is internalized by inhalation, ingestion,
absorption through the skin or mucous membranes or entry through a
wound. Internal contamination may result in incorporation, which is the
entry of radioisotopes across cell membranes into the cell.

5.3.6.3. *Incorporation*. Different radioisotopes have varying
affinities for different organs and have varying residence times in the
body. Some may collect in the bone, whereas others may collect in the
thyroid or other organs. The radioactive form of a substance is
processed through the same metabolic pathways as the non-radioactive
form of that substance. Thus physiological changes, medications and
procedures that alter the usual metabolic pathways for a chemical will
alter the likelihood and rate of incorporation. The radioactive material
is eliminated from the body through sweat, blood, tears, urine and
feces. This process of elimination is referred to as de-corporation, and
the rate of release may be increased by certain medications.

5.3.6.4. *Exposure or Irradiation*. Radioactive materials give off
energy in the form of photons or particles. The photons or particles
behave like light waves coming from a light bulb, but at a much higher
energy level and are invisible. When an individual is exposed to
radiation (also termed irradiation), he or she is not contaminated; but
the radiation passes through the body. A patient getting a chest x-ray
is a good example of irradiation. The patient has been exposed to
radiation but is not contaminated. An individual that has been exposed
is not radioactive, and presents no hazard to response personnel.

5.3.7. ***Adverse Health Effects***. To properly care for the radiation
accident victim, a timely diagnosis of the magnitude of the accident
must be determined. Adverse health effects of radiation exposure can
range from mild effects, such as reddening of the skin, to long-term
effects such as cancer or even eventual death. The severity of health
effects is determined by the amount of radiation absorbed by the body,
the type of radiation, the route of exposure and the exposure time.
There are several resources for the management of the clinical
manifestations of the radiation accident patient. (See the sample SOP,
Patients with Radiation Exposure or Radioactive Contamination in Section
6.2.3.3. for detailed information.) An important resource is the
Radiation Emergency Assistance Center/Training Site (REAC/TS)
[www.orau.gov/reacts](http://www.orau.gov/reacts).

5.3.8. ***Protection of Response Personnel***.

5.3.8.1. *Time, Distance and Shielding*. Time, distance and shielding
are the three golden principles of radiation protection. These three
principles are common sense, when you think about them. The less time
you spend near a radioactive source, the less your radiation exposure
will be. Increasing your distance from the radioactive source is a very
effective tool in reducing your exposure. For gamma and x-ray sources
(penetrating radiation), every time you double your distance away from
the source, the exposure rate drops by four times; therefore, even a
small amount of distance can make a big difference in your exposure.
Many materials can be used as shielding; lead and concrete are two
effective shielding materials. Make use of existing shielding, such as
concrete walls or something as simple as stepping around the side of a
building. Utilize time, distance and shielding together to minimize your
radiation dose. (Example: when you do not have to be right next to the
contaminated patient, take a step or two back, reducing the time and
increasing the distance in order to lower your exposure.)

5.3.8.2. *Respiratory Protection*. For situations involving airborne
particulate radioactive material, standard surgical masks are usually
sufficient. A higher level of protection would be a High Efficiency
Particulate Air (HEPA) filter, such as the N95 mask that is commonly
available in the hospital setting. Fit testing and training must be
provided for the N95 mask. If radioactive vapors (such as iodine 131)
are involved, a respirator with an organic vapor cartridge must be
employed.

5.3.8.3. *Skin Protection*. Personal protective equipment (PPE) includes
all clothing and protective gear worn to protect individuals from
hazards. The wearer must demonstrate competency to don and doff properly
and provide proper maintenance. Protection levels for PPE are classified
as A, B, C and D, with D being the least protective. Level C is usually
sufficient when working with a radiation contamination event. Hospital
surgical gowns or Tyvek suits with nitrile gloves are examples of
appropriate protective clothing. Refer to the sample Healthcare First
Receiver Decontamination Readiness Plan in Part 1 of this Section for
more information.

5.3.8.4. *Dosimetry*. Personnel handling contaminated victims must wear
radiation dosimetry badges in order to monitor the amount of their
radiation exposure. One type of dosimeter is a clip-on badge containing
film or other radiation-sensitive material, such as a thermo luminescent
dosimeter (TLD). Other types are pocket ionization chambers, electronic
dosimeters or electronic alarming rate meters that chirp when the
radiation level exceeds a pre-set level. The later has been referred to
as "radiation pagers." The Radiation Safety Officer will distribute
dosimeters.

5.3.9. ***Medical Considerations of Contaminated Victims***. Medical
conditions and traumatic injury [must]{.underline} be assessed before
consideration is given to radiation contamination. Triage and
stabilization of patients take first priority before initiating
decontamination procedures. Removal of the clothing removes
approximately 80-90% of the contamination. The next priority will be the
decontamination of skin and wounds. Signs and symptoms of high radiation
exposure should be noted. An important step in radiation dose
determination is the time to onset of emesis. Swabs of all body orifices
should be taken for radiation analysis. Nasal swab activity represents
approximately 5% of the deposition in the lung. An initial blood count
should be taken and repeated every 4 hours to monitor the lymphocyte
count.

5.3.10. ***Decontamination of Victims***. Decontamination procedures
should only be initiated after the patient is medically stabilized.
Conventional trauma injuries always take first priority, as skin or
wound contamination is almost never immediately life threatening. Open
wounds should be covered during skin decontamination to prevent
contamination from re-entering the wound. Clothing removal reduces
contamination up to 80-90%. Contaminated clothing should be placed in
plastic bags and held for proper disposal. Personal items should also be
placed in plastic bags for later decontamination and a proper
chain-of-custody procedure followed.

5.3.10.1. *Skin Decontamination*. After clothing removal, the skin
should be gently washed with soap and water, using gentle brushing. Do
not scrub hard enough to abrade the skin; this could potentially cause
internalization of the contamination. The goal is to remove as much
contamination as possible. The radiation level should be reduced to
twice background or lower. If successive decontamination attempts fail
to reduce the contamination level by 10%, the contaminated area should
be covered and standard blood borne pathogen precautions should be
utilized when handling the patient. When covered, sweating will reduce
the contamination level to some extent. Hair may be decontaminated with
any commercial shampoo or by clipping. Fluid may prevent weak beta or
alpha emitters from being detected.

5.3.10.2. *Wound Decontamination*. Abrasions, lacerations and puncture
wounds compromise the skin's integrity, thus increasing the route to
internalize the radioactive material. Following contamination with
radioactive material, wounds may contain radioactive dust or shrapnel.
Radioactive shrapnel should be handled with forceps and, if found to be
radioactive, placed in a lead-lined container (if available) at least
six feet from personnel.

5.3.10.3. *Internal Treatment*. The first priority is to assess
traumatic injuries or other emergent medical conditions. When the
patient's condition permits, steps should be taken to assess if internal
contamination has occurred. Swabs from all body orifices and urine and
fecal samples should be taken and analyzed for radioactive material
content. If internal contamination is confirmed, treatment should begin
in order to reduce internal contamination. Internal contamination may be
reduced by minimizing absorption of radionuclides and increasing the
excretion. The chemical toxicity must also be considered when
eliminating internal contamination. Side effects of de-corporation of
radionuclides must be weighed against the long-term effects of the
radiation exposure. Available pharmaceuticals for immediate treatment
include the administration of potassium iodide (KI), if radioiodine is a
suspected agent; antacids to decrease gastrointestinal absorption for
uranium or strontium; and, cathartics to decrease residence
time/absorption in the bowel, such as biscodyl or phosphate soda enema
to flush the colon quickly. Aluminum-containing antacids are
particularly effective for decreasing the uptake of strontium between
50-85%. For large intakes of ingested radioactive material, gastric
lavage is effective, but only if given within one to two hours after
ingestion.

5.3.11. ***Radiological Assessment and Biodosimetry***. Assessing
injured victims includes taking radiation measurements and collecting
information relevant to decontaminating and treating the patient.
Medically stable patients should not be released for ambulance transport
until a radiological survey has been performed. The instrument used to
conduct the radiation survey should be able to detect penetrating and
non-penetrating radiation (a Geiger-Mueller Counter with a pancake or
end-window probe). The probe should be moved about one inch per second,
taking care not to touch the probe to the potentially contaminated
patient. The distribution of contamination on the patient should be
recorded, and nasal swabs taken to assess if contaminants were inhaled.
Information about the nature of the radioactive source should be
collected from the patient. If details of the source and time of
exposure are determined, a reasonable radiation dose estimate may be
possible. Consult the facility Radiation Safety Officer for radiological
assessment information and interpretation.

5.3.12. ***Biodosimetry Assessment Tool***. The Biodosimetry Assessment
Tool (BAT), developed by the Armed Forces Radiobiology Research
Institute (AFFRI), is a software program that aids in the collection and
interpretation of clinical manifestations of radiation exposure. The BAT
archives and analyzes clinical information, and provides a radiation
dose estimate for the patient. The program can be downloaded at:
[http://www.afrri.usuhs.mil/www/outreach/biodostools.htm -
software](http://www.afrri.usuhs.mil/www/outreach/biodostools.htm#software)

5.3.13. ***Morgue Operations***.

5.3.13.1. *Autopsies*. Performing autopsies of cadavers with minimal
contamination only requires contamination control methods and
appropriate protective clothing. Highly contaminated cadavers with
exposure readings of 0.1 to 1.0 mGy/hr should have several individuals
split the task. If the exposure event is being handled as a criminal
case, the case must be performed in coordination with the medical
examiner or coroner.

5.3.13.2. *Embalming/Cremation*. Embalmers should wear protective
clothing and preferably have radiation safety staff present to monitor
contamination. Embalming and cremation are contingent upon the amount
and type of radioactive material the cadaver is contaminated with.
Burial is usually not an issue, unless there is long-lived radionuclides
present that may enter the environment. Cremation is dependent on the
type and concentration of radionuclides released to the environment by
incineration or by ash disposal. If the radionuclide is short-lived,
waiting a few weeks before cremation may be advisable.

5.3.14. ***Psychological Aspects of a Radiological Event***. An attack
with the release of radioactive material can create fear, anxiety and
mass panic reactions among the general public. Following an attack, the
management of psychological and behavioral responses can be just as
important as the medical treatment and decontamination of the victims.
For the majority of the people, psychological symptoms related to the
traumatic event will fade over time. Although for others, symptoms may
persist, affecting function at work and home, and may result in further
psychiatric complications. Acute stress disorder, post-traumatic stress
disorder, depression, increased substance abuse, family conflict and
generalized anxiety disorder may also be experienced.

5.3.15. ***Exercise Scenarios***.

5.3.15.1. Radiological Dispersal Device (Dirty Bomb).

Scenario Description - A terrorist group has obtained approximately 250
grams of Plutonium-238 (Pu-238) and has constructed a radiological
dispersal device (RDD). The explosive device is constructed with plastic
explosives that incorporate immediate and delayed blasting caps and
flyer plate technology to penetrate a propane storage tank, and detonate
the expanding propane cloud within one second after the explosion. The
explosive device and radioactive material (Pu-238) are placed on a
1500-gallon propane tank located in a central area of the city. The
device is detonated mid-afternoon on a normal workday.

Effects - The explosion causes small fires in the vicinity of the
propane tank. The Pu-238 is dispersed primarily in the blast direction.
The wind speed is 15 mph from the north with humidity at 50%. A 500
mRem/hour zone extends 400 feet wide and one-half mile in length. Pu-238
deposition of 4 uCi/square meters occurs along the dispersion area.

Actions - Local police and fire units respond to the explosion, and
local area residents come to see the fire. Fifteen people in the
vicinity of the blast have traumatic injuries and radioactive
contamination. Forty-five individuals in the dispersion area are
contaminated, but not injured. The local newspaper has received a call
from the terrorist group claiming the explosion has spread radioactive
material all over the city. Greater than 1000 patients are estimated to
present for decontamination citywide.

5.3.15.2. Improvised Nuclear Device (IND).

Scenario Description - A terrorist group has acquired a sufficient
amount of highly enriched uranium (HEU) and has constructed an IND with
a gun implosion mechanism. The IND is put in a car trunk on the top
level of a five-story parking garage. The parking garage is open on the
sides and top, and is located approximately 100 yards adjacent to the
County Court building in a large metropolitan city. The weapon is
detonated mid-afternoon on a normal workday. The explosive yield is 1.5
kilotons.

Effects - The explosion causes a shock wave of greater than 200-psi
static overpressure at ground zero. The parking garage and County Court
building are destroyed. All of the 750 individuals in the County Court
building are killed, and 50 people in the parking garage are also
killed. The blast radius projects 360 degrees, and the amount of
devastation varies from total destruction near ground zero to moderate
damage at the edges of the blast radius. The maximum overpressure at 440
yards from ground zero is approximately 15 psi, 5 psi at one-half mile,
3 psi at three-quarters mile, and 2 psi at one mile. Several thousand
individuals are killed, and many have sustained traumatic injuries from
the blast with second-degree burns from the intense heat generated.
Thermal burns are experienced as far as two miles out. Glass windows in
buildings in a one-mile radius are shattered, causing additional
injuries. Unprotected individuals within one-half mile of the detonation
have received lethal doses of gamma and neutron radiation. Radioactive
fallout is dispersed downwind, contaminating individuals and the
environment. Electric power in the area is knocked out, and water and
natural gas lines are ruptured.

Actions - Local police and fire units respond to the explosion. The
newspaper gets a call from the terrorist group claiming the explosion
was a nuclear weapon and that there are more bombs around the city.
Greater that 100,000 patients are likely to present for decontamination
citywide.

Attachment:

A. Radiological Performance Evaluation Matrix

Section 5 - Part 4

Sample Chemical Event

And Terrorism Readiness Plan

5.4.1. ***Introduction***. The Chemical Event and Terrorism Readiness
(ChETR) Plan is a component of the VA Medical Center (VAMC) Emergency
Operations Plan (EOP) that addresses the unique characteristics of a
chemical release or spill. The ChETR Plan is to be used for any chemical
hazard or threat, accidental or intentional, that may be encountered by
the VA Medical Center or any community emergency event in which the VA
Medical Center may be asked to assist. The Plan is structured to use the
Incident Command System (ICS) and implement Standard Operating
Procedures (SOPs) for any specific chemical event that is likely to be
encountered. Special considerations must be given when considering a
chemical event that is internal to the facility versus an event external
to the facility outside of the danger or plume zone.

Initial recognition of a chemical event is usually not problematic. With
a few important exceptions, a spill or release of most chemical agents
cause abrupt onset of symptoms immediately recognized as dangerous
and/or life threatening by the individuals exposed. Key in the initial
response, coordination of communications and ongoing activities at the
site of the spill or release, will be technician level trained first
responders from local fire departments and other emergency medical
service personnel. Fire-fighters and hazardous materials (HAZMAT) teams
trained at the technician level are the only personnel that should be
dealing with the true "hot zone" at the site of the spill in which the
potential for conditions immediately dangerous to health and life (IDHL)
exist. Secondary responders, or personnel with a special need to enter
the spill site zone, may do so under the direct supervision and guidance
of trained first responders. Hospital personnel preparing to receive
patients from the zone of exposure, implement hospital decontamination
procedures and treat patients being transported from the zone of
exposure to the hospital are classified as hospital based first
receivers. Hospital first receivers by definition are operating in a
clean zone away from the site of the spill or release, and wear a
minimum of OSHA (Occupational Safety and Health Administration) Level C
personal protective equipment (PPE) to protect them from contaminants
contained on the clothing or skin of the victims who are arriving at the
facility. Pre-planning for potential events based upon local risk and
hazards vulnerability analysis (HVA) and involvement of a
multi-disciplinary hospital response team is key in a successful safe
response.

Both accidental and intentional events should be considered when
developing response plans and conducting drills to prepare for a
potential chemical event. Historically, medical centers are most
prepared for dealing with casualties from a small accidental chemical
release, such as that from an industrial site or transport vehicle in
which the agent is immediately known due to Department of Transportation
(DOT) regulations requiring standardized labeling of both transportation
vehicles and containers. Expectations in the accidental spill/release
setting are that there will probably be a small number of patients
arriving, that the agent will be known or declared by the time the
patient arrives and that most seriously contaminated patients will be
decontaminated at the site of the spill by first responder HAZMAT teams.
Household spills may only involve one or two individuals and the history
of how and why the spill or exposure occurred is usually well
documented, along with the offending agent.

The story is expected to unfold quite differently in the setting of an
intentional or terrorist chemical release event. A few situations that
may indicate the possibility of a Chemical Warfare agent release include
the following:

-   Unusual, unexplained outdoor animal deaths (birds, squirrels,
    outdoor pets, etc.).

-   Unexpected absence of insects and the scattering of wildlife.

-   Multiple serious casualties all arriving from a similar setting or
    same site.

-   Nausea, vomiting, disorientation, muscle twitching, pinpoint pupils,
    difficulty breathing or seizures.

-   Report of unusual, unexplained liquid, spray or vapor.

-   Droplets with a very oily film detected in the air or from an air
    conditioning/heating air ventilation system.

-   Reports of unexplained odors (e.g., garlic, horseradish, geraniums,
    freshly mowed hay).

-   Low clouds or fogs unrelated to the weather.

-   Suspicious containers, spraying devices or leaking packages.

In this setting, the agent in question will probably be unknown or at
best unverified, the number of casualties much greater and the degree of
panic or chaos extremely high. Patients may be arriving in a state of
fear and panic via self-transport means without previous
decontamination. Attention must immediately be given to facility
security and lockdown, establishing the facility Emergency Operations
Center (EOC) and rapid, safe deployment of the hospital decontamination
team. Patient triage should be based on signs and symptoms at
presentation and reassessed frequently. (See sample SOP, Triage During a
Mass Casualty Incident, in Section 6.3.3.4. for an example.) Antidotes
for any anticipated, high-risk events should be available whenever
possible. Activation of the emergency Pharmacy Cache supplies may be
required in such an event. (See sample VHA Pharmaceutical Cache SOP,
Section 6.3.3.6, for an example.)

It is important to remember that in either the accidental or intentional
release of a chemical agent, conditions may change significantly over
time; and any plan developed should allow flexibility, as any of the
following may change due to weather conditions:

-   Plume danger zone.

-   Evacuation routes.

-   Controlled safe zones of hospital decontamination operations, as
    directed by the Safety Officer and EOC.

-   Routes of approach to the hospital decontamination unit.

-   Routes of approach to the alternate Emergency Room for
    non-contaminated patients with non-event related emergencies (chest
    pain, gunshot wound, broken bones, etc.).

-   Plan for receipt and distribution of critical supplies (water,
    medical supplies, etc.).

5.4.2. ***Purpose***. The purpose of the Chemical Event and Terrorism
Readiness (ChETR) Plan is to describe how the VA Medical Center will
respond to chemical disaster events. This Plan addresses policy
requirements, assumptions and processes for a VA Medical Center-wide
coordinated response that focuses on safety of the work environment for
the protection of our patients, employees, facility and community.

5.4.3. ***Scope***. This Chemical Event and Terrorism Readiness (ChETR)
Plan applies to all employees, ensures compliance with Joint Commission
on Accreditation of Healthcare Organizations (JCAHO) and OSHA
requirements, and implements the VA Medical Center's strategy for
responding to all potential chemical related emergency events in the
hospital receiver role. It is designed to respond and protect the well
being of patients, employees and all occupants within the VAMC, protect
the physical infrastructure and allow for business continuity to the
fullest extent possible.

Specific sample Standard Operating Procedures (SOPs) based on specific
threats thought most likely to be faced can be found in Section 6 of
this Guidebook. These SOPs, developed as a result of the Hazard
Vulnerability Analysis (HVA), define the mitigation, preparedness,
response and recovery efforts necessary to minimize the potential
adverse impact from chemical events most likely to be encountered.

5.4.4. ***Policy***. In the event of a chemical disaster, the VA Medical
Center will implement the Chemical Event and Terrorism Readiness (ChETR)
Plan to make certain the necessary services are provided to ensure a
safe environment for all occupants. The VA Medical Center will work
closely with the community to ensure effective interaction during
response and recovery.

5.4.5. ***Notification Processes and Contact Information***. Healthcare
facilities may be the initial site of recognition and response to
external chemical events, particularly if physically located near the
site of the spill or release. Notification should immediately include
the facility hospital Director, healthcare providers, Engineering,
hospital Safety Officer, Clinical Laboratory Director, Environmental
Management Service chief and other clinical and administrative service
chiefs.

If appropriate, the Office of the Director will activate the Emergency
Operations Center (EOC) and will coordinate with all internal services,
Network Director, Department of Health, FBI field office, local police,
CDC and medical emergency services.

5.4.5.1. Internal Facility Contact Numbers:

Hospital Director \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Chief of Staff \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Safety Officer \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Clinical Laboratory \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Engineering \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Environmental Management \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Nutrition and Food Service \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

5.4.5.2. External Contacts:

Network Director \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Area Emergency Manager \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Health Department \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Local FBI Field Office\* \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\*(See Attachment A - FBI Field Office Contact Numbers.)

Local Medical Facility Contacts:

University Hospital \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Hospital A \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Hospital B \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Hospital C \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Hospital D \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Initial Notification to Network (VISN) Director should include:

-   Facility name and location of event or impact area (e.g., site of
    the release or spill).

-   Name and position of reporting official.

-   Incident Command station phone number and ICS manager's name.

-   Short Situation Report (to include type of chemical event, clinical
    symptoms and level of diagnostic certainty, e.g., suspected agents,
    presumptive diagnosis or confirmed agent).

-   Chronological order of events, to include number of patients
    received to date.

-   Immediate and projected short-term resource needs.

-   Status of Public Health Service notification.

-   Summary of all other agencies or facilities to be notified.

5.4.6. ***United Nations Hazard Classes***. Consideration of the various
types of chemical agent classes, the types of compounds within each
class and the potential clinical effects of exposure are very helpful.
The Table 5-4.1 below lists the chemical agents as outlined by the
United Nations Hazard Class system that are linked to the Department of
Transportation (DOT) hazardous materials listings. Chemicals can be
referred to using the specific chemical name or United Nations Number
using the UN/NA/PIN (United Nations/North American/PIN) system. Caution
must be noted that multiple chemicals may have the same United Nations
number! It is always best to explore potential chemical agents and their
effects by specific chemical names whenever possible. Each of the
chemical classes noted in the Table below may result in significant
injury to the cardiovascular system, central nervous system, respiratory
system, gastrointestinal system, skin and eyes. Special considerations
are noted whenever a generalized caution or clinical issue/impact should
be remembered.

**Table 5-4.1 - United Nations Hazard Classes**

+------+-----------+-------------------+-------------------------------+
| **Un | **Agent** | **Examples**      | Special Considerations        |
| ited |           |                   |                               |
| Nat  |           |                   |                               |
| ions |           |                   |                               |
| Cla  |           |                   |                               |
| ss** |           |                   |                               |
+------+-----------+-------------------+-------------------------------+
| 1    | E         | TNT, dynamite     | Methemoglobinemia;            |
|      | xplosives |                   |                               |
|      |           |                   | Blast Trauma (see sample      |
|      |           |                   | trauma response plan and      |
|      |           |                   | SOPs).                        |
+------+-----------+-------------------+-------------------------------+
| 2.1  | Flammable | Butane, propane,  | BLEVE potential at site of    |
|      | Gases     | acetylene,        | spill/release; expect burn    |
|      |           | hydrogen          | and trauma.                   |
+------+-----------+-------------------+-------------------------------+
| 2.2  | Non-      | Nitrogen, helium, | BLEVE potential at site of    |
|      | flammable | xenon, nitrogen   | spill/release; expect burn    |
|      | Gases     | CO2               | and trauma.                   |
+------+-----------+-------------------+-------------------------------+
| 3    | Co        | Brake fluid,      | Avoid epinephrine and beta    |
|      | mbustible | camphor, glycol   | agonists due to risk of       |
|      | and       | ethers, benzene,  | Ventricular fibrillation.     |
|      | flammable | gasoline, acetone |                               |
|      | liquids   |                   |                               |
+------+-----------+-------------------+-------------------------------+
| 4    | Flammable | Phosphorus,       | Caution: Brush particles away |
|      | solids    | lithium,          | from skin in dry setting;     |
|      |           | potassium,        | then decon patients with      |
|      |           | magnesium,        | copious amounts of water. If  |
|      |           | titanium, calcium | water reactive agents are     |
|      |           | resinate          | embedded in the skin do       |
|      |           |                   | [not]{.underline} apply water |
|      |           |                   | due to explosion risk. Cover  |
|      |           |                   | area with mineral oil, and    |
|      |           |                   | transport for surgical        |
|      |           |                   | debridement. If phosphorus is |
|      |           |                   | embedded, do                  |
|      |           |                   | [not]{.underline} apply       |
|      |           |                   | mineral oil as it promotes    |
|      |           |                   | dermal absorption.            |
+------+-----------+-------------------+-------------------------------+
| 5.1  | Oxidizers | Calcium chloride; | Agents are corrosive and may  |
|      |           | lithium peroxide  | be extremely sensitive to     |
|      |           |                   | heat and shock.               |
|      |           |                   | Life-threatening pulmonary    |
|      |           |                   | edema, circulatory collapse   |
|      |           |                   | and laryngeal edema.          |
+------+-----------+-------------------+-------------------------------+
| 5.2  | Organic   | Benzoyl peroxide, | Agents are corrosive and may  |
|      | Peroxides | peracetic acid,   | be extremely sensitive to     |
|      |           | methyl ethyl      | heat and shock.               |
|      |           | ketone peroxide   | Life-threatening pulmonary    |
|      |           |                   | edema, circulatory collapse   |
|      |           |                   | and laryngeal edema.          |
+------+-----------+-------------------+-------------------------------+
| 6    | I         | Tear gas, riot    | May see significant           |
|      | rritating | control agents,   | respiratory tract symptoms;   |
|      | materials | mace              | most mild exposures only      |
|      |           |                   | require supportive measures.  |
+------+-----------+-------------------+-------------------------------+
| 2    | Poisons A | Cyanide, arsenic, | CVS and respiratory collapse  |
| and  | and B     | phosgene,         | risk; some cause severe CNS   |
| 6    |           | pesticides,       | depression; airway and        |
|      |           | methyl bromide,   | circulatory and seizure       |
|      |           | aniline           | control essential. Some may   |
|      |           |                   | have specific antidotes       |
|      |           |                   | (Cyanide and pesticides).     |
+------+-----------+-------------------+-------------------------------+
| 6    | Et        | Viable            | Symptomatic and supportive    |
|      | iological | micro-organisms   | care should be begun          |
|      | Agents    | (anthrax, HIV,    | immediately. Always use       |
|      |           | tetanus,          | Standard Precautions as       |
|      |           | botulinum, etc.)  | minimum PPE level. See        |
|      |           |                   | Biologic Event and Terrorism  |
|      |           |                   | Response Plan and SOPs.       |
+------+-----------+-------------------+-------------------------------+
| 7    | Rad       | Plutonium,        | Exposure versus contamination |
|      | ioactives | cobalt, etc.      | distinction critical. See     |
|      | I, II and |                   | Radiological Event and        |
|      | III       |                   | Terrorism Response plan and   |
|      |           |                   | SOPs.                         |
+------+-----------+-------------------+-------------------------------+
| 8    | C         | Strong acids and  | Do not attempt to neutralize  |
|      | orrosives | bases with pH     | products, as risk of          |
|      |           | less than 2.5 or  | exothermic reactions (water + |
|      |           | greater than      | agent = HEAT) exists. Do not  |
|      |           | 12.5. HCl, NaOH,  | use emetics; protect airway;  |
|      |           | potash            | consult Safety officer        |
|      |           |                   | regarding PPE.                |
+------+-----------+-------------------+-------------------------------+

> CNS = Central Nervous System; BLEVE = Boiling Liquid Expanding Vapor
> Explosion (BLEVE) potential; HIV = Human Immunodeficiency Virus.

5.4.7. ***Pre-planning Considerations for Chemical Events***. The best
approach for an ongoing response plan for a chemical event requiring
hospital based first receiver activities is to use a multidisciplinary
team for planning, team development, ongoing refinement and assessment
through drills and exercises. Utilize the expertise of employees with
the following skills whenever possible:

-   Safety Officer

-   Industrial Hygienist and/or Chemist

-   Firefighters

-   Decontamination training (especially those with military experience)

-   Police and Security

-   Engineering

-   Nursing Service and Providers

-   Emergency Room Physician

-   Public Health Specialist

-   Environmental Management Services

-   Public Affairs officer

5.4.7.1. *Facility Lockdown*. It is important that the established plan
allow for immediate facility lockdown and immediate initiation of
emergency hospital decontamination procedures whenever a potential event
is suspected. (See sample SOP on Lockdown - Heightened Security
Procedures in Section 6.3.4.3.) Awaiting a hierarchy of approval after
complete confirmation that an event has occurred only adds to the risk
that panicked victims rushing through hospital doors seeking care will
contaminate the medical facility. If available, video camera access to
the area immediately surrounding the Emergency Room entrance door, along
with an intercom system, can help Emergency Room personnel address the
fears and concerns of arriving victims, as hospital personnel don their
Level C PPE. The initial victims arriving at the medical facility will
generally be the least injured and can be coached to walk through
self-showering (or, if a fixed facility is available, full
self-decontamination), while the Decontamination Team is gearing up to
exit the facility and assist these and other victims who will be seeking
assistance.

5.4.7.2. *Secondary Events*. Extreme caution should always be taken by
the Decontamination Team, as potential for secondary events may not only
occur at the site of the initial release, but at anticipated response
facilities, such as major hospitals. Secondary events may include bombs,
additional chemicals, radiological materials or biologic agents. It is a
good idea to include the hand-held Geiger counters as a standard part of
operational equipment, just in case a radiological element has been used
in the intentional terrorist event.

5.4.7.3. *Police and Security*. Police and Security assistance is
essential in maintaining facility lockdown and a safe perimeter around
the Medical Center. Consideration can be given to developing an
emergency security personnel network (ESPN) within the hospital
personnel pool system with people who can be trained by facility Police
to assist in focused tasks such as door lockdown maintenance and
corridor route control within the facility. This allows the Police to be
at the front-line of the event with the Decontamination Team,
maintaining order and outdoor perimeter safety. As outlined by OSHA,
Police who are dressed and outdoors in Level C gear, require Operations
Level training on an ongoing basis.

5.4.7.4. *Interlinking Response Plans and SOPs*. The Chemical Event and
Terrorism Response Plan will interlink often with other response plans
and SOPs in the overall VA Medical Center Emergency Management Plan.
These will be referenced whenever possible and should be referred to for
more detailed information. These include response plans and SOPs for:
Healthcare First Receiver Decontamination; Pharmaceutical Cache;
Biologic Events; Radiological Events; Mass Casualty Evacuations;
Disaster Triage; and Trauma Management.

5.4.7.5. *Syndrome-Based Criteria*. Rapid response to a chemical event
requires prompt identification of its onset and rapid patient triage and
treatment. In the event of a chemical injury, the difference of minutes
to decontamination and treatment can make tremendous clinical impact.
Hospital first receivers and VA Medical Center medical personnel must
expect that treatment will begin based on symptoms of the patients
presenting or being brought in from the site of the spill or release.
Although laboratory testing is available to confirm the presence of many
agents, these are generally not available in the hospital clinical
laboratory setting. Table 5-4.2 below may serve as a quick reference of
potential presentations, outlining predominant symptoms or syndromes and
agents for consideration. This listing is [not]{.underline} intended to
be all-inclusive, but a generalized grouping of some of the most likely
presentations and most likely agents for considerations.

####### Table 5-4.2 - Clinical Syndromes in a Chemical Event

+-------------------------------+--------------------------------------+
| **Syndrome**                  | **Potential Agents to Consider**     |
+===============================+======================================+
| Skin rash, blistering and/or  | Lewisite; Phosgene oxime; anhydrous  |
| burns with immediate pain,    | ammonium; hydrogen chloride;         |
| redness and blistering within | hydrogen fluoride; hydrogen sulfide. |
| seconds to minutes.           |                                      |
+-------------------------------+--------------------------------------+
| Skin rash, blistering and/or  | Sulfur Mustard; Nitrogen Mustard;    |
| burns with latency period     | trichothecene (T-2 mycotoxins).      |
| (hours to sometimes 2 days)   |                                      |
| prior to symptoms, redness    |                                      |
| and/or blistering.            |                                      |
+-------------------------------+--------------------------------------+
| Predominant pulmonary         | Pulmonary agents (phosgene, PFIB,    |
| symptoms developing rapidly   | diphosgene, chlorine, oxides);       |
| (seconds to minutes after     | Lewisite; Phosgene oxime; anhydrous  |
| exposure).                    | ammonium; sulfur dioxide; hydrogen   |
|                               | chloride; hydrogen fluoride;         |
|                               | hydrogen sulfide; T-2 mycotoxins.    |
+-------------------------------+--------------------------------------+
| Predominant pulmonary         | Phosgene; Mustard agents; Ricin;     |
| symptoms developing more      | Abrin; T-2 mycotoxins;               |
| slowly (hours to days after   | Staphylococcal enterotoxin B (SEB).  |
| exposure).                    |                                      |
+-------------------------------+--------------------------------------+
| Seizures and/or sudden coma   | 1\. Nerve agents: Tabin \[GA\];      |
| (symptoms may develop within  | Sarin \[GB\]; Soman \[GD\] and VX.   |
| seconds to minutes; sometimes | (Mixed glandular secretions and      |
| a few hours if mild exposure  | skeletal muscle fasciculation:       |
| by dermal route only).        | Atropine and 2-Pralodoxime chloride  |
|                               | antidotes!).                         |
|                               |                                      |
|                               | 2\. Organophosphates (Mixed          |
|                               | glandular secretions and skeletal    |
|                               | muscle fasciculation: Atropine and   |
|                               | 2-Pralodoxime chloride antidotes!).  |
|                               |                                      |
|                               | 3\. Blood agents: hydrogen cyanide;  |
|                               | cyanogens (Flushing with excessive   |
|                               | 'pinkness,' almond odor may be noted |
|                               | by some; remember cyanide antidote   |
|                               | kits!).                              |
|                               |                                      |
|                               | 4\. Hydrogen sulfide (gasping        |
|                               | breaths followed by collapse, coma   |
|                               | and seizures).                       |
+-------------------------------+--------------------------------------+
| Acute Non-immune Hemolytic    | Arsine (heavy gas with garlic like   |
| Anemia (anemia develops       | or 'fishy' odor noted by those       |
| within 2- 24 hours of         | exposed). Used in industry           |
| exposure).                    | (especially in development of        |
|                               | computer chips and fiber optic       |
|                               | equipment).                          |
+-------------------------------+--------------------------------------+

5.4.7.6. *Matrix-Based System for Agent Categorization*. Another system
that can be used to place an unknown agent into a specific category is
the Chemical Agent Indicator Matrix, (based on example in Jane's
Chem-Bio Handbook, 2^nd^ edition, pp.20-23). This system is designed
specifically around the chemical warfare agents, so this must be
remembered if this system is used by emergency medical personnel. In
this system all chemical warfare agents are grouped into five categories
as follows:

> A = Nerve Agents
>
> B = Blister Agents
>
> C = Cyanide
>
> D = Pulmonary Agents
>
> E = Riot Control Agents

Table 5-4.3 - Chemical Agent Indicator Matrix

(A=Nerve Agent; B=Blister Agent; C=Cyanide; D=Pulmonary Agent; E=Riot
Control Agent)

  ------------------------------------------------ -------- ------- -------- -------- --------
  **Physical Indicator Noted in Examination**      **A**    **B**   **C**    **D**    **E**

  **Appearance**                                                                      

  Prostration                                      X        \-      X        \-       \-

  Twitching                                        X        \-      X        \-       \-

  Convulsions                                      X        \-      X        \-       \-

  Coma                                             X        \-      X        \-       \-

  Bleeding from mouth                              X        \-      X        \-       \-

  Coughing                                         X        \-      X        X        X

  Sneezing                                         X        \-      X        \-       X

  Vomiting                                         X        X       X        \-       X

  Fasciculations (muscle twitching)                X        \-      \-       \-       \-

  **Skin**                                                                            

  Cyanosis (bluing of skin)                        X        \-      X        \-       \-

  Gray area of dead skin                           \-       X       \-       \-       \-

  Pain, irritation                                 \-       X       X        X        X

  Clammy                                           X        \-      X        \-       \-

  Sweating, localized or generalized               X        \-      \-       \-       \-

  **Eyes**                                                                            

  Small pupils                                     X        \-      \-       \-       \-

  Normal, large pupils                             X        X       X        X        X

  Involuntary closing                              \-       \-      X        \-       X

  Tearing                                          X        \-      X        X        X

  Burning, irritation                              \-       X       X        X        X

  Headache, pain around eyes                       X        \-      \-       \-       \-

  Dim vision                                       X        \-      \-       \-       \-

  Blurred vision                                   X        \-      \-       \-       \-

  Burning pain in eyes                             \-       X       X        X        X

  Redness                                          X        \-      \-       \-       X

  **Respiratory**                                                                     

  Coughing                                         X        \-      X        X        X

  Runny nose                                       X        \-      X        X        X

  Tight chest (shortness of breath)                X        \-      X        X        X

  Burning, irritation of nose                      \-       X       X        X        X

  **Cardiovascular**                                                                  

  Slow heart rate                                  X        \-      \-       \-       \-

  Fast heart rate                                  X        \-      X        X        X

  **Digestive System**                                                                

  Defecation/diarrhea                              X        \-      X        \-       \-

  Nausea                                           X        X       X        \-       X

  **TOTAL**                                                                           

  Total possible indicators in each agent group    **26**   **8**   **23**   **11**   **16**
  (A, B, C, D, E)                                                                     
  ------------------------------------------------ -------- ------- -------- -------- --------

X = possible finding within agent group; - = not expected for agent.
Note: Circle the symptoms noted, and tally up each column to determine
most likely chemical warfare agent group, based on comparison to
expected symptoms.

5.4.7.7. *Special Considerations for Mission Critical Engineering
Systems*. In the setting of any chemical event, it is essential to
involve facility Engineering personnel, the Safety Officer and the
Industrial Hygienist in the patient management planning processes in
order to ensure maintenance of a safe facility environment for both
hospital personnel and our patients. Areas within the expertise of
Engineering that must be included in the planning process include:

-   Heating, Ventilation and Air-Conditioning (HVAC) System management.

-   Steam Distribution Systems.

-   Room and Hood exhaust integrity.

-   Water Delivery Systems.

-   Water Conditioning/Drinkability.

-   Critical Supplies and Equipment Resources.

-   Internal Transportation Systems (Pneumatic tubes, elevators, robotic
    systems, food service transportation needs).

-   External Transportation Systems (Vans, etc.).

-   Medical Gases maintenance.

-   Electrical distribution.

-   Communications.

Involving Engineering in the planning and disaster management process
will ensure that mission critical engineering systems essential to
maintaining facility integrity will be properly monitored and preserved.

5.4.8. ***Post Exposure Management***.

5.4.8.1. *Decontamination of Patients and Environment*. In an event in
which patients are grossly contaminated with an unknown substance or a
known chemical compound, standard hospital receiver decontamination
protocols should be implemented. (See sample Healthcare First Receiver
Decontamination Readiness Plan, Part 1 of this Section; and sample
Healthcare First Receiver Decontamination SOP, Section 6.3.3.2.) Any
unknown substance gross contamination could potentially represent a
biologic agent, chemical agent with delayed symptoms or radiological
agent. Potentially harmful practices, such as bathing patients with
bleach solutions, are unnecessary and should be avoided. Clean water,
saline solution or commercial ophthalmic solutions are recommended for
rinsing eyes. VAMC personnel will be stationed at both the male and
female ambulatory self-decontamination sites to assist in any way, and
to ensure that decontamination proceeds in an organized, calm fashion.
Designated VAMC employees will escort all patients who have showered and
changed to a large secure designated waiting area. (See sample
Healthcare First Receiver Decontamination Readiness Plan, Part 1 of this
Section; and sample Healthcare First Receiver Decontamination SOP,
Section 6.3.3.2.) The FBI may require collection of exposed clothing and
other potential evidence for submission to FBI or Department of Defense
(DoD) laboratories to assist in exposure investigations. (See sample
Chain of Custody Readiness Plan in Part 6A of this Section.) Plans for
containment of contaminated run-off should be made jointly with
Engineering, Safety and local authorities.

5.4.8.2. *Triage and Management of Large Scale Exposures and Suspected
Exposures*. In the event of a large-scale release, the processes for
triage, safe housing and medical care for potentially large numbers of
affected individuals will follow the Emergency Preparedness Mass
Casualty Plan. Triage and management planning for large-scale events may
include:

-   Establishing networks of communication and lines of authority;
    coordinating on-site care.

-   Establishing networks of communication internally to provide
    continuous staff education and status reports, and to maximize
    education while minimizing rumor, fear and panic.

-   Planning for cancellation of non-emergency services and procedures.

-   Planning with Nutrition and Food Service for anticipated needs.

-   Planning with Environmental Management Services to ensure
    appropriate EMS staff receive education and are aware of procedures
    to follow during a chemical event to ensure their safety.

-   Identifying sources able to supply available vaccines, immune
    globulin, antibiotics, and anti-toxin (with assistance from local
    and state public health departments).

-   Planning for the efficient evaluation and discharge of patients.

-   Developing discharge instructions for patients determined to be
    non-contagious or in need of additional on-site care, including
    details regarding if and when they should return for care or if they
    should seek medical follow-up.

-   Determining availability and sources for additional medical
    equipment and supplies (e.g., ventilators) that may be needed for
    urgent large-scale care.

-   Planning for the allocation or re-allocation of scarce equipment in
    the event of a large-scale event (e.g., duration of ventilator
    support of terminally afflicted individuals).

-   Coordinating with Pathology service; identifying the institution's
    ability to manage a sudden increase in the number of cadavers on
    site.

5.4.8.3. *Psychological Aspects of a Chemical Terrorism Event*.
Following an accidental or intentional chemical terrorism event, fear
and panic can be expected from patients, hospital personnel and members
of the community. Psychological responses following these events may
include horror, anger, panic, unrealistic concerns about contamination,
paranoia, social isolation and demoralization. Mental health support
personnel (e.g., psychiatrists, psychologists, social workers, clergy
and volunteer groups) will assist in collaboration efforts to address
the immediate and subsequent mental health needs of the patients,
hospital personnel and family members. The hospital Director and Public
Affairs Officer or their designees will coordinate with the media. The
Emergency Operations Center and medical officers will coordinate with
external Emergency Medical Services. Local, state and federal experts
may also provide assistance with communications and education needs.

When developing this plan, consideration of the following was made to
address *patient and general public* fears:

-   Minimize panic by clearly explaining risks, offering careful but
    rapid medical evaluation/treatment, and avoiding unnecessary
    isolation.

-   Treat anxiety in unexposed persons who are experiencing somatic
    symptoms (e.g., with reassurance, or diazepam-like anxiolytics as
    indicated for acute relief of those who do not respond to
    reassurance).

When developing this plan, consideration of the following was made to
address *healthcare worker* fears:

-   Provide chemical event (accidental or intentional terrorist events)
    education, including frank discussions of potential risks and plans
    for protecting healthcare providers.

-   Invite active, voluntary involvement in the chemical event and
    terrorism readiness planning process.

-   Encourage participation in disaster drills.

-   Fearful or anxious healthcare workers may benefit from their usual
    sources of social support or by being asked to fulfill a useful role
    (e.g., as a volunteer at the triage site).

5.4.9. ***Laboratory Support and Confirmation***. VA Medical Center
Pathology and Laboratory Medicine Service has a full service clinical
laboratory. The laboratory may participate as a member of the Centers
for Disease Control and Prevention (CDC) Laboratory Response Network
(LRN) and enjoy the benefit of standardized training sessions on
collection of specimens and transport of specimens to the CDC in the
event of a chemical disaster. Specimens for transport will be packaged
in accordance with Department of Transportation (DOT) guidelines for
shipping of hazardous materials. VA Medical Centers work with county,
state and federal public health service representatives to tailor
diagnostic strategies to specific events. Currently the Bioterrorism
Emergency Number at CDC is at the Emergency Response Office, National
Center for Environmental Health (NCEH), 770-488-7100.

5.4.9.1. *Obtaining Diagnostic Samples*. For specific recommendations on
diagnostic sampling for each type agent, contact the local Public Health
service laboratory. The Laboratory Response Network chemical event
protocol emphasizes the types of blood and urine samples to send, need
for "background" empty tubes and containers for each sample, consent and
chain of custody requirements and forms and shipping requirements.
Sample collection should be performed in accordance with Standard
Precautions. The CDC website for Laboratory Protocols and the Laboratory
Response Network Guidebook is helpful when dealing with specific agents
or syndromes. See sample Chain-of-Custody Readiness Plan (Part 6A of
this Section) to ensure compliance with chain-of-custody requirements
from the point of specimen collection. The Laboratory Response Network
guidebook provided by the Public Health Service Laboratory to each local
hospital also includes shipping information and a PHS Chain-of-Custody
form for all samples submitted for evaluation during a chemical disaster
event.

5.4.9.2. *Transport Requirements*. Specimen packaging and transport will
be coordinated with local and state health departments, the Laboratory
Response Network and the FBI. Packaging materials and transport media
will be chosen by VAMC clinical laboratory in collaboration with these
entities. For specific instructions, contact the Bioterrorism Emergency
Number at the CDC Emergency Response Office, 770-488-7100 or the state
Public Health Laboratory, Bioterrorism Preparedness Coordinator
[\_\_\_\_\_\_(name)\_\_\_\_\_\_\_]{.underline} at [(phone)]{.underline}
.

5.4.9.3. *CDC Laboratory Response Network*. The Centers for Disease
Control and Prevention established the Laboratory Response Network (LRN)
per Presidential Decision Directive 39, dated 1995. This Directive
outlined national anti-terrorism policies and assigned specific missions
to federal departments and agencies. Through a collaborative effort
involving LRN founding partners, the Federal Bureau of Investigation and
the Association of Public Health Laboratories, the LRN became
operational in August 1999. Its objective was to ensure an effective
laboratory response to bioterrorism by helping to improve the Nation's
public health laboratory infrastructure, which had limited ability to
respond to bioterrorism.

Today, the LRN is charged with the task of maintaining an integrated
network of local public health, federal, military and international
laboratories that can respond to both bioterrorism and chemical
terrorism. The LRN is a unique asset in the nation's growing
preparedness for biological and chemical terrorism. The linking of state
and local public health laboratories, veterinary, agriculture, military
and water-and food-testing laboratories is unprecedented.

The Laboratory Response Network (LRN) and its partners will maintain an
integrated national and international network of laboratories that are
fully equipped to respond quickly to acts of chemical or biological
terrorism, emerging infectious diseases and other public health threats
and emergencies.

5.4.9.4. *Tissue Handling and Post-Mortem Care*. Pathology and
Laboratory Medicine Service should be informed of any potential chemical
contamination prior to submitting specimens for examination or bodies
for autopsy or disposition. Pathology and Laboratory Medicine Service
will use standard protocols for handling potentially contaminated bodies
and tissues. Post-mortem examinations will be coordinated with the State
Medical Examiner or coroner. In the event of a terrorist event-related
death, all tissues and reports become critical evidence and will be
handled in accordance with state and federal law. Instructions will be
given to funeral directors in cooperation with the Medical Examiners
office before any bodies or remains are released.

5.4.10. ***Patient, Visitor and Public Information***. Clear,
consistent, understandable information will be provided (e.g., via fact
sheets) to patients, visitors and the general public. Visitors may be
limited at the discretion of the hospital Director and the EOC. Crowd
control will be the responsibility of VAMC Police and Security who may
be assisted by VAMC volunteers, if appropriately trained and approved by
Police and Security. Military personnel may also be utilized in response
to mass casualties, as designated by state and federal leaders, and
approved by the Department of Defense (DoD).

The Office of the Director for Public Affairs personnel will disseminate
information to the media. Failure to provide a public forum for
information exchange may increase anxiety and misunderstanding,
increasing fear among individuals who attribute non-specific symptoms to
exposure to the bioterrorism agent.

5.4.11. ***Drills and Exercises***. The reality of facing a
community-wide, region-wide or statewide chemical disaster is a daunting
consideration, regardless of whether it is an accident or an intentional
chemical release. The latter would, of course, instill a greater degree
of fear and urgency. No hospital expects to be able to completely handle
such an event without difficulty. The more training and education
provided, the more comfortable healthcare providers feel about dealing
with such an event.

Knowledge without practice is a fading process bound for failure. In
order to ensure constant readiness, drills and exercises should be
performed often and must present increasingly challenging situations as
expertise and comfort levels rise. (See Section 9, Education, Training
and Exercises.) With any plan, it is important to actually practice the
things that employees are least familiar with \-- things they don't do
in their day-to-day employment, such as:

-   Donning and Doffing of PPE.

-   Practicing lifting techniques using litters and carts.

-   Practicing washing techniques (head to toe; front to back).

-   Utilizing emergency communication devices (head sets; hand-held
    radios, etc.).

-   Utilizing emergency hand-signals, for those in PPE who do not have
    radios.

-   Collecting materials for tracking of evidence within a crime scene.

After each drill, tabletop exercise or practice sessions analyze:

-   What was done best?

-   What could have been done better?

-   What were the major problems?

-   What can we do to improve the process?

-   When can we next test our capabilities and try these improvements to
    see how well they actually work?

**Scenario 1:** You have received a call from Emergency Medical System
(EMS) personnel that an 18-wheeler has wrecked, and is now leaking
phosgene oxime along a highly populated area. You are cautioned to
prepare to receive casualties in about 30-35 minutes. Estimated injured
at this point are 10, and patients will be distributed to all responding
hospitals (expect 1-3 casualties per facility at this point).

**Considerations:** You know the agent, and you have time to quickly
look it up and refresh the Emergency Department personnel on expected
findings. The numbers are small, and patients are being distributed in
an organized fashion throughout the city. Phosgene oxime is a pulmonary
agent, so symptomatic respiratory support is essential. Have personnel
for intubation assistance and ventilator support ready if needed. You
should activate the Hospital Decontamination Team; you do not know for
sure that other area residents have not been exposed, and they could be
on the way to your facility for treatment. Although phosgene oxime is
primarily a pulmonary agent, any contamination of the casualties could
place your hospital employees at risk of secondary exposure. Chemical
should be removed before patients enter the facility. Those being
transported by ambulance from the scene have been thoroughly
decontaminated.

**Scenario 2:** An accident has occurred at the nearby chemical
stockpile arsenal, and you are the responding hospital. Two workers
exposed to sarin are being transported; they have both received two
Mark-1 injections and are in stable condition.

**Considerations:** The numbers are small, and you know the agent and
the estimated level of exposure (One Mark-1 = Mild exposure; Two Mark-1s
= Moderate exposure; Three Mark-1s and Diazepam = severe exposure). Have
antidote (Mark-1s or injectable atropine and 2-PamCl) ready should
symptoms be persistent upon arrival of casualties. Workers have been
thoroughly decontaminated at the arsenal by personnel well-versed in
accidents of this type. Remember: Vapor exposure peaks quickly (within 1
hour) and subsides quickly; liquid exposures may be delayed and the peak
may not occur for up to 24 hours.

**Scenario 3:** An explosion at a nearby chemical facility has caused
the release of agents, as yet undetermined. The Sara Title III report
notes that the plant contains predominately corrosives and a limited
supply of oxidizers. Emergency personnel at the scene have been unable
to specify which tanks have been affected and what chemical or mix of
chemicals has been released. There were 34 workers in the plant at the
time of the explosion, and all have been decontaminated at the scene and
are in transport to local medical facilities.

**Considerations:** You don't know what the agents are here. More
importantly, there is the potential of mixed agents with unknown new
reactants formed by the combination of these agents. Prepare for contact
cautions and respiratory support. Decontamination is essential. Activate
Hospital Decontamination Team immediately to assist in receipt of
patients and decontamination of anyone self-presenting. If the
decontamination status is unknown, the patients should be run through
the hospital decontamination procedure. This is to ensure protection of
the medical facility, employees and patients.

**Scenario 4:** Excited football fans have gathered in the open-air
stadium for a major season-end championship game. Early in the game a
plane flew overhead and just seconds later, spectators noticed a fine
mist of liquid material. Emergency first responders are on the scene and
have organized a decontamination system; however, crowd control is
impossible and people are scattering quickly, leaving the scene and
running to the nearest medical facilities. Estimated attendance at the
game is 38,000. There are 10 hospitals in the nearby area, and the
closest hospitals are the University, the VA Medical Center and Baptist
Hospital. EMS personnel report predominately panic, with no localized
symptoms at this moment.

**Considerations:** You don't know what the agent is or if there really
is an agent involved. This could be water used as a hoax to cause mass
panic and disruption. Think, however, of agents with a known delay
period, such as mustard agents. This could be mustard. Real or hoax, you
will not know for sure for sometime. Activate Hospital Decontamination
Team immediately and prepare for a large ongoing response. Facility
lockdown and perimeter control by VA Medical Center Police is critical
to maintaining safety of facility.

Section 5 - Part 5

Sample Trauma Readiness for

All-Hazards Disaster Response Plan

5.5.1. ***Introduction.*** The national capacity to manage events with
trauma patients must increase as the risk of terrorism in the United
States increases. Natural events may also produce overwhelming numbers
of trauma victims in one or multiple localities. The Trauma Readiness
for All-Hazards Disaster Response (TRADR) Plan is a component of the VA
Medical Center (VAMC) Emergency Management Plan (EMP). The TRADR Plan is
to be used for any disaster, naturally occurring or intentional, that
may be encountered by the VA Medical Center (VAMC); external emergencies
declared by the Veterans Administration/ Department of Defense (VA/DoD);
and any community emergency event in which the VA Medical Center may be
asked to assist. This sample readiness plan is structured to use the
Incident Command System (ICS), and implement Standard Operating
Procedures (SOPs) for any specific disaster that is likely to involve
mass casualty trauma victims. This sample plan will support multiple
Emergency Operations Plans (EOPs) within the Emergency Management Plan,
including any natural or terrorist event plan in which mass casualties
with trauma may be involved.

Healthcare facilities must meet specific criteria for designation as a
specific Trauma Level site. However, in a mass casualty event involving
multiple trauma victims in which community resources are overwhelmed,
hospitals and clinics not usually called upon to provide trauma care may
receive victims through self-referral, delivery by privately-owned
vehicle, and by default when transportation routes to the usual sites of
trauma care are blocked. Transportation directly to the site where
definitive care can be provided is the first delivery-site priority of
Emergency Medical Service (EMS) transport. However, situations arise
when this is not possible, yet victims must be transported from an
unsafe environment to an accessible secondary hospital or clinic. These
secondary sites become defacto triage and emergency treatment areas.
Life-saving measures must not be denied for arrivals simply because the
facility is not designated as a trauma facility. Provision of emergency
care and stabilization until transport to the appropriate site is
possible may be lifesaving. Although this sample TRADR Plan addresses
such a contingency, in **no** situation should the victim be transported
to a non-trauma or lower-level facility when access to the appropriately
designated facility or a facility with more appropriate resources is
available. Activation of the TRADR Plan will occur primarily in response
to a Mass Casualty Incident. \[Refer to the sample Healthcare First
Receiver Decontamination Readiness Plan (Part 1 of this Section), and
sample Healthcare First Receiver Decontamination Standard Operating
Procedure (Section 6.3.3.2.).\]

The major goal of an effective trauma response plan is to improve the
outcome of injured victims through the timely provision of the most
appropriate care available. Component goals are to stabilize the patient
with minimization of morbidity and mortality through the provision of
safe and effective treatment at the earliest possible time until
definitive care is available, and to maximize the efficiency of patient
transfer and transport to the appropriate facility. These goals are
based upon the concept of the "golden hour" of care following injury.
Effective internal and external communication pathways must be
incorporated into the plan to achieve these goals. The VAMC utilizes the
Incident Command Structure to effect these communication pathways.
Ongoing local needs analysis and situation status reports are utilized
to enhance response efficiency.

VAMC facilities must have trauma control policies in place authorizing
the appropriate staff to rapidly implement appropriate measures in
response to a potential or actual event. A community emergency
department communication system, with pre-event Memorandum Of
Understanding (MOU) between all community medical facilities and a
clearly-developed overall community transfer coordination center are
essential in achieving the maximum patient outcome from a community or
larger mass casualty event.

Important characteristics of trauma include the mechanism of injury; the
severity, type and extent of injury; prior health status or special
characteristics of the victim (i.e. pregnancy, pediatric or geriatric
patient, underlying medical conditions, etc.); and the status of wound
contamination. Management of an event with multiple trauma victims
necessitates an understanding of the epidemiology of patient
presentation. The availability of effective trauma response protocols
will serve as a major mitigation strategy. Sufficient personnel and
equipment, along with the availability of decontamination and an
understanding of when it is indicated, are critical to a safe and
effective response plan. A cooperative response plan including the
medical center surgical team, emergency department providers, primary
care and medical providers, along with clinical leadership, hospital
administration and clinical support services working together as a team,
make an effective trauma response plan possible.

In an event requiring activation of the TRADR Plan, the internal
communication network must include the hospital Director, Police, Chief
of Staff, Chief of the Emergency Department, Chief of Surgery and
surgical subspecialty chiefs, Chief of Anesthesiology, Operating Room
personnel, Chief of Medicine, all other clinical and administrative
service chiefs, healthcare providers, Blood Bank and clinical Laboratory
personnel, Radiology personnel, Chaplain Service, Social Work Service,
Acquisition and Materiel Management Service, the Public Affairs Officer,
hospital Safety, Engineering and Environmental Management Services.
External notification will include the Network Director, and may be
extended to include the Federal Bureau of Investigation (FBI) field
office, the American Red Cross Blood Bank, burn centers and organ
transplantation affiliates.

Commitment to periodic disaster preparedness drills is necessary to
assure operative capability. The use of both mini-component testing
drills and major full-scale drills provides testing of program
effectiveness and improvement in readiness and response capacity. In
addition, encouragement of participation by physicians and nurses in
specific training in trauma management will improve the ability to
minimize morbidity and mortality in such events.

Community response and panic reduction will be facilitated through
skillfully disseminated information. On going communication with other
local medical facilities will be necessary to ensure appropriate
transfer of the victims at the proper time.

5.5.2. ***Purpose***. The purpose of the TRADR Plan is to describe how
the VAMC will respond to both terrorist related threats/events or to
naturally occurring disasters involving multiple trauma casualties. This
readiness plan addresses policy requirements, assumptions and processes
for a VAMC-wide coordinated response that uses the Incident Command
Structure and related SOPs. This plan focuses on a safe and effective
delivery of care in trauma events, thus enhancing protection for our
patients, employees, facility and community.

5.5.3. ***Scope***. This TRADR Plan applies to all employees, ensures
compliance with Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) requirements, and implements the VAMC strategy for
responding to all emergency events potentially involving trauma that
requires activation of the Emergency Operations Plan (EOP). It is
designed to facilitate a response that protects the well being of
patients, employees and the community, while protecting the physical
infrastructure, and allowing for business continuity to the fullest
extent possible.

Information based on trauma situations most frequently encountered can
be found in paragraph 5.5.7. of this Plan. However, this plan is not to
be used as a medical treatment guide. It is not possible to cover all
trauma scenarios in this plan or to provide clinical care guides, as
such an endeavor would encompass the specialties of emergency medicine
and surgery. Thus, the introductory basics for the most lifesaving and
frequently anticipated scenarios are addressed and are designed to serve
as a stimulus for further study and development.

This TRADR Plan and all SOPs developed as the result of the Hazard
Vulnerability Analysis (HVA) define mitigation, preparedness, response
and recovery efforts designed to minimize the potential adverse impact
most likely to be encountered from the threats and events involving mass
casualty trauma victims.

5.5.4. ***Policy***. In the event of an emergency or disaster with
anticipated multiple trauma victims, the VAMC will implement the TRADR
Plan to provide the necessary services to ensure a safe environment for
all patients, visitors and staff and to provide necessary medical
services to victims of the event. The VAMC will work closely with the
community to ensure effective interaction during response and recovery.
(Disclaimer: The information in the sample Trauma Readiness Plan and/or
sample Trauma SOP is not intended to be used as the primary source for
treatment information. Clinicians are responsible for providing care
within their level of expertise and credentialing.)

5.5.5. ***Notification Processes and Contact Information***. Healthcare
facilities may be the initial site of response to terrorism events
involving traumatic injuries. If a terrorism event is suspected, local
emergency response systems should be activated. Notification should
immediately include the hospital Director, Police, Chief of Staff, Chief
of the Emergency Department, Chief of Surgery and surgical subspecialty
chiefs, Chief of Anesthesiology, Operating Room personnel, Chief of
Medicine, all other clinical and administrative service chiefs,
healthcare providers, Blood Bank and clinical Laboratory personnel,
Radiology personnel, Chaplain Service, Social Work Service, Acquisition
and Materiel Management Service, the Public Affairs Officer, hospital
Safety, Engineering and Environmental Management Services.

If appropriate, the Office of the Director will activate the Emergency
Operations Center (EOC) and will coordinate with all internal services,
VISN Director, Department of Health, FBI field office, local police and
medical emergency services. The EOC will coordinate patient tracking
with the Emergency Department and Surgical and Medical Services, and
monitor all patients and potentially-exposed staff, reporting data
through the Office of the Director to the appropriate agencies.

5.5.5.1. Internal Facility Contact Numbers:

Hospital Director
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Chief of Staff
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Emergency Department Director
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Chief of Surgery
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Chief of Anesthesiology
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Chief of Medicine
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Blood Bank \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Clinical Laboratory
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Radiology \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Operating Room Supervisor
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Chief of Orthopedics
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Chief of Vascular Surgery
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Chief of Neurosurgery
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Chief of Otolaryngology
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Chief of Ophthalmology
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Chief of Dental
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Plastic Surgery
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Police \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Chaplain \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Safety Officer
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Engineering \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Environmental Management Service
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Nutrition and Food Service
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Acquisition & Materiel Management Svc.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Social Work Service
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Public Affairs Officer
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

5.5.5.2. External Contact Numbers:

Network Director
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Area Emergency Manager
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

American Red Cross
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Local Medical Flight Services
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Regional Medical Flight Services
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Local Burn Unit(s)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Regional Burn Unit(s)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Health Department
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Local FBI Field Office
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\*

\*(See Attachment A - FBI Field Office contact numbers)

Local Medical Facility Contacts:

University Hospital
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Hospital A \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Hospital B \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Hospital C \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Hospital D \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

5.5.5.3. Initial Notification to Network (VISN) Director should include:

-   Facility Name and location of event or Impact Area (e.g. Emergency
    Department).

-   Name and position of reporting official.

-   Incident Command Station contact number and ICS managers name.

-   Short Situation Report (to include type of event, estimate of
    casualties, types of injuries).

-   Chronological order of events (to include number of patients
    received to date).

-   Immediate and projected short-term resource needs.

-   Status of Public Health Service Notification.

-   Summary of all other agencies or facilities to be notified.

5.5.6. ***Responsibilities***.

-   *Medical Center Director or Designee* is responsible to act as the
    Incident Commander/Manager (IC), and is responsible for all VAMC
    response planning and actions.

-   *Emergency Program Coordinator (EPC)* is responsible to ensure that
    the EOP is current, assists the IC with internal (Key Operations
    Managers) and external (community or agency) coordination.

-   *Chief of Staff* is responsible for providing proper medical,
    health, and treatment care services.

-   *Associate Director* is responsible for monitoring and ensuring VAMC
    operations and services as they relate to patient services are
    implemented.

-   *Emergency Department Director* is responsible for ensuring
    Emergency Department personnel are familiar with the trauma
    readiness plan and SOP and participate in trauma related educational
    endeavors and drills to assure ability to respond to a MCI with
    trauma. Key role in developing and maintaining functional trauma
    procedures/protocols in conjunction with Chief of Surgery for a MCI
    with trauma.

-   *Emergency Room Personnel* - Key role in patient reception, triage,
    stabilization, treatment and disposition. Key role in ensuring that
    all other medical emergency capabilities (i.e., cardiac emergencies)
    are maintained and operational.

-   *Chief of Surgery* is responsible for developing and maintaining
    functional trauma procedures/protocols in conjunction with the
    Emergency Department Director.

-   *Chief of Anesthesiology/Anesthesiology Staff* are responsible for
    providing supportive services to assist with intubation and airway
    access, intravenous access and anesthesiology services as indicated.

-   *Chief of Medicine* is responsible for assuring ongoing patient
    care, providing appropriate medical services as needed in support of
    patients from the event, for collaborating with the Emergency
    Department Director and Chief of Surgery as needed to assure optimum
    patient support.

-   *Medical Service* - Key role in clinical care of patients in
    conjunction with Surgery Service to assure timely and appropriate
    stabilization and treatment of patients. Key role in maintaining
    continuity of patient care operations and monitoring clinical
    patient workload. Key role in identifying clusters of clinical signs
    or symptoms that could indicate exposure to a chemical, biological
    or radioactive contaminant in the incident.

-   *Chief of Nursing/Nursing Service -* Key role in tracking patient
    census, staffing utilization and need for additional staff.
    Encourages nursing staff in educational endeavors on trauma
    management.

-   *Chief of Radiology/Radiology Staff* are responsible for providing
    radiological support services. In Mass Casualty Incidents (MCIs)
    with trauma, the number of functional x-ray machines and the rate of
    processing may be the limiting factor in the processing of victims.
    Interventional Radiology services will probably be needed to assist
    with line placement and diagnostic testing. CT and Ultrasound
    services will have key roles in patient assessment.

-   *Infection Control Team* - Provides information as needed, for
    health care providers, employees and patients regarding concerns
    related to infection control, with emphasis on any staff exposed to
    blood and body fluids.

-   *Clinical Laboratory* - Provides collection and analysis of
    biological specimens as needed to support clinical care. Blood Bank
    plays a key role in providing cross matching and blood components as
    indicated.

-   *Safety Officer* is responsible for monitoring and initiating
    actions to ensure safe actions are taken during the emergency event.

-   *Safety Officer/Industrial Hygienist* - When potential or actual
    contamination is involved, key role as the point of contact with
    HAZMAT agencies in substance sampling or environmental sampling. Key
    role in monitoring and proper use of specialized PPE resources as
    needed.

-   *Public Affairs* will act as the point of contact for the media and
    other governmental agencies that may request information concerning
    the incident and its impact upon patients, staff, and facility.

-   *Police Chief* ensures that lockdown and security procedures,
    traffic and crowd control, crime scene and investigation, and
    perimeter control are implemented.

-   *Police Service* is responsible for perimeter control and incident
    site access. Key role in maintaining chain-of-custody for all
    potential evidence during investigation of potential terrorist
    events within the VAMC or when victims of the incident enter the
    VAMC.

-   *Occupational/Employee Health* - Key role in monitoring occupational
    health conditions/risks, employee concerns and prophylactic therapy
    as needed. Tracks and provides care and documentation for any
    employee exposed to blood or body fluids.

-   *Chief Engineer* is responsible for protecting, repairing and
    maintaining plant utility systems, communications and medical
    equipment necessary for patient care and VAMC operation.

-   *Chief A&MMS* is responsible for logistical function relating to
    providing facilities, transportation, supplies, equipment, services,
    etc.

-   *Chief Fiscal* is responsible for providing funding and tracking
    expenses that relate to VAMC response to the emergency event.

-   *Social Work -* Coordinates information between victims and their
    significant other and family.

-   *Chaplain* - Provides spiritual counsel and comfort to the victims
    and their significant other and family, with special emphasis on
    those victims who are terminal.

-   *Human Resource Management* - In a Mass Casualty Incident involving
    the community, provides information to significant other or family
    of workers on site and acts as liaison during an extended event in
    coordination with Public Affairs.

5.5.7. ***Mass Casualty Event Trauma***. Healthcare providers commonly
treat a variety of injuries in medical practice. However, mass casualty
events from either terrorist events or natural disasters may produce
injuries not usually encountered in medical practice situations in the
United States. For example, injuries involving blast trauma are
primarily encountered on the battlefield and, thus, may be unfamiliar to
the majority of civilian practitioners. The increased threat of
terrorist activities mandates that providers be prepared to address such
injuries. Burns, traumatic amputations, penetrating eye injuries,
impaled shrapnel, blast lung, rupture of internal viscera and minimal
brain injury (MBI) are some of the injuries to be expected following a
bomb blast. If the blast occurred within a closed space or if structural
collapse is involved, the severity of injury will be increased. Special
populations, such as the very young, the very old, pregnant patients and
immuno-compromised patients, will present special challenges in trauma
situations. In addition, the possibility of the concomitant use of dual
or multiple agents, such as radioactive materials, chemicals or
biological agents, must be considered. The need for decontamination and
the proper order of decontamination and trauma care must be addressed.
The interactive effects of trauma and radiation, chemical, or biological
agents on the clinical course of the patient must also be recognized and
addressed.

In order to prepare providers for this increased threat, a number of
on-line resources are available for self-study and review of the
mechanisms of injury, triage, first aid, management and treatment of
such patients. In addition, courses on trauma and disaster medicine for
physicians, nurses and pre-hospital responders are available. One such
course, which was developed by the American College of Surgeons for
education on the management of trauma patients, is the Advanced Trauma
Life Support for Doctors^^ course. Other courses are available for
pre-hospital and hospital providers of trauma care, including nurses and
other non-physician personnel.

Please refer to the Trauma Management in a Mass Casualty Incident sample
SOP (Section 6.3.3.5.) for a discussion of the types of injuries
produced by specific effects of blast injury. For further information,
see the Center for Disease Control and Prevention web site dealing with
trauma. Components of blast injury include the compression wave, the
thermal wave, flying debris, structural collapse, psychological trauma
and physical exertion from escape or rescue efforts.

Additional considerations include the increased risk of infection from
exposure to blood and body fluids when multiple trauma victims are
involved.

5.5.8. ***Trauma Control Practices for Patient Management***. The
management of trauma patients must be well organized and rehearsed.
Strong leadership and effective communication are paramount. The VHA
Pharmaceutical Cache includes components that provide additional
resources for trauma management at the facility during an emergency
situation. (Refer to the sample VHA Pharmaceutical Cache Readiness Plan
in Part 6B of this Section.) Because most VAMCs are not designated as
trauma centers, established transfer procedures, protocols, and MOUs
with community and state facilities are needed.

5.5.9. ***Infection Control Practice and Standard (Universal)
Precautions***. Patients and trauma victims carrying transmissible
diseases such as Hepatitis B, Hepatitis C and HIV are not readily
identifiable. Thus all patients in healthcare facilities should be
managed utilizing Standard (Universal) Precautions with the appropriate
personal protection equipment (PPE). Standard Precautions are designed
to reduce transmission from both recognized and unrecognized sources of
infection in healthcare facilities and are recommended for all patients
receiving care, regardless of their diagnosis. Using Standard
Precautions with all patient encounters provides a consistent
standardized level of protection for hospital personnel. In situations
involving trauma, the risk of contamination with body fluids is high,
and utilization of Standard Precautions is essential to protect patient,
provider and staff. The use of eye protection and facemasks in such
situations should be emphasized in these situations. Effective use of
Standard Precaution measures prevents direct contact with all body
fluids (including blood), secretions, excretions, non-intact skin
(including rashes) and mucous membranes. Standard (or Universal)
precautions routinely practiced by healthcare providers include
handwashing, gloves, face protection and gowns/lab coats.

Other standard procedures should be followed for the safe handling of
items exposed to blood or other body fluids. Such procedures include the
safe disposition of sharps, the proper cleansing of spills and
non-disposables and appropriate safety practices such as avoiding
recapping of needles.

If exposure to blood or body fluids does occur, existing hospital policy
should be followed. Facilities should ensure that such policies are in
place to identify and manage hospital personnel exposed to infectious
patients. Careful documentation of potential exposures must be
maintained and employees should be encouraged to complete appropriate
workplace exposure documentation forms. In general, maintenance of
accurate occupational health records will facilitate identification,
contact, assessment and delivery of post-exposure care to potentially
exposed healthcare workers. Coordination between Infection Control and
Employee Health services as well as effective employee communication is
essential to maintain awareness and minimize panic.

Refer to Part 2 of this Section, sample Biologic Event and Terrorism
Readiness Plan, for further information on Infection Control practices.

5.5.10. ***Triage and Management of Large Scale Mass Casualty Trauma
Incidents***. In the event of a large-scale mass casualty event
involving many trauma patients, processes for triage and medical care
for potentially large numbers of affected individuals will follow the
Emergency Preparedness mass casualty plan. Triage and management
planning for large-scale events may include:

-   Establishing networks of communication and lines of authority,
    coordinating on-site care.

-   Establishing networks of communication both internally and
    externally to provide continuous information on resource
    availability and facilitate appropriate transfer as indicated by the
    situation internally and externally.

-   Establishing networks of communication internally to provide
    continuous staff education and status reports, to maximize education
    while minimizing rumor, fear and panic.

-   Planning for cancellation of non-emergency services and procedures.

-   Coordinating with Blood Bank regarding anticipated needs.

-   Coordinating with Surgery and Anesthesiology Services as well as
    Operating Room Management for management of a surge of cases
    requiring operative interventions.

-   Planning with Environmental Management Services to ensure
    appropriate EMS staff education and awareness of procedures during a
    trauma event to ensure their safety.

-   Identifying sources able to supply available vaccines, immune
    globulin, antibiotics, and anti-toxin (with assistance from local
    and state public health departments).

-   Planning for the efficient evaluation and discharge of patients.

-   Developing discharge instructions for patients following appropriate
    treatment, including details of medical follow-up.

-   Determining availability and sources for additional medical
    equipment and supplies (e.g., ventilators, IV pumps and supplies)
    that may be needed for urgent large-scale care.

-   Planning for the allocation or re-allocation of scarce equipment in
    the event of a large-scale event (e.g., duration of ventilator
    support of terminally afflicted individuals).

-   Coordinating with Pathology service, identifying the institution's
    ability to manage a sudden increase in the number of cadavers on
    site.

-   Coordinating with transplantation services for obtaining donor
    organs from newly expired victims when time allows.

5.5.11. ***Trauma Management of the Grossly Contaminated Patient***.
Decontamination of Patients and Environment. In an event in which
patients are grossly contaminated with an unknown substance, standard
hospital receiver decontamination protocols should be implemented. Any
such unknown substance contamination could potentially represent a
chemical agent with delayed symptoms, a radiological agent or a
biological agent. Practices such as bathing patients with bleach
solutions are potentially harmful, are unnecessary, and should be
avoided. Vigorous scrubbing with abrasion of the skin should similarly
be avoided, as such dermal irritation will enhance the absorption of
agents. Washing with water or soap and water is usually sufficient.
Clean water, saline solution or commercial ophthalmic solutions are
recommended for rinsing eyes. (For more details refer to Part 1 of this
Section, sample Healthcare First Receiver Decontamination Readiness
Plan; and Section 6.6.3.2, sample Healthcare First Receiver
Decontamination SOP.)

Actual decontamination for a biological event should be needed only when
gross contamination is involved. Refer to the sample Biologic Event and
Terrorism Readiness Plan (Part 2 of this Section) for assistance with
decisions regarding the need for antibiotic prophylaxis and other
specifics of an event involving biological contamination.

The FBI may require collection of exposed clothing and other potential
evidence for submission to FBI or Department of Defense laboratories to
assist in exposure investigations. (See sample Chain-of-Custody
Readiness Plan, Part 6A of this Section.)

5.5.12. ***Discharge Management of the Trauma Patient***. Ideally,
patients with trauma will not be discharged from the facility until they
are recovered sufficiently to be able to care for themselves. In the
event that the large numbers of persons involved preclude admission of
all injured patients, home-care instructions will be distributed to
affected individuals who have adequate resources in the home to assist
with injury management. Home healthcare agencies and public health
nurses may be needed to assist with post-event in-home management of
these patients. Depending on the injury, home care instructions may
include recommendations for wound care, infection control practices,
signs and symptoms of wound infection and dates, times and location of
return for follow-up. Phone contact numbers will be provided to all
discharged and/or released patients, so that they may call back to the
VAMC with any additional concerns or questions.

5.5.13. ***Psychological Aspects of Trauma***. Psychological stress is a
component of traumatic events. Patients, providers, hospital personnel
and community members can be expected to experience varying degrees of
anxiety, fear, and panic. Persons may experience an acute stress
reaction and in some cases a long-term reaction known as post-traumatic
stress disorder (PTSD.) Persons at greater risk for development of PTSD
include those with closer proximity to the event, a prior history of
trauma, a history of past-unresolved stressors or a cluster of multiple
stressors. Mental health support personnel (e.g., psychiatrists,
psychologists, social workers, clergy and volunteer groups) may also
assist in collaborative efforts to address the immediate and subsequent
mental health needs of those involved.

Appropriately sensitive and skilled communication of information is
vital to management of both the event and the psychological aspects. The
hospital Director and Public Affairs Officer or their designee will
coordinate with the media. Specialized training in risk communication
should be available and encouraged for those who will interact with the
media in such events. Local, state and federal experts may also provide
assistance with communications and educational needs. Information on
coping with traumatic events is available on the web for both patients
and professionals. (See the CDC website on Mass Trauma -
<http://www.bt.cdc.gov/masstrauma/copingpub.asp>.)

When developing this plan, patient and general public fears were
addressed through the following considerations:

-   Clearly explaining procedures, risks and benefits, and offering
    careful but rapid medical evaluation/treatment will reduce panic.

-   Acute anxiety in uninjured persons and relatives of the injured may
    be reduced through calmly delivered truthful information and
    appropriate support through the Chaplain and Social Work services as
    indicated by the situation. Anxiolytics, such as Lorazepam, may be
    indicated for acute relief of those in extreme distress who are
    medically stable.

When developing this plan, consideration of the following was made to
address healthcare worker fears:

-   Provide terrorism readiness education, including frank discussions
    of potential risks and plans for protecting healthcare providers.

-   Invite active, voluntary involvement in the planning for events
    involving mass casualties with trauma and in the terrorism readiness
    planning process.

-   Encourage further education in first aid and trauma management
    classes.

-   Encourage participation in disaster drills.

-   Fearful or anxious healthcare workers may benefit from their usual
    sources of social support, or by being asked to fulfill a useful
    role (e.g., as a volunteer at the triage site, to assist with family
    contact, etc.).

Section 5 - Part 6

Special Considerations

A. Sample Chain-of-Custody Readiness Plan

5.6.1. ***Introduction*.** Chain-of-custody is a conceptual-driven
process in jurisprudence that applies to documenting the handling of
evidence. The chain-of-custody procedure assures continuous
accountability designed to withstand the documentation requirements
associated with legal challenge. If not properly maintained, an entire
evidentiary item may not be admissible in court.

The chain-of-custody document is a chronologically written record of
those individuals who have had custody of the evidence from its initial
acquisition until its final disposition. It identifies the location,
transfer and security of the evidence from collection to disposal, and
provides documentation that identifies each person having true
possession of the evidence and any actions taken along the course (e.g.,
photographs, testing). A complete, detailed and chronological
chain-of-custody procedure is necessary documentation for civil and
criminal cases.

The discussion that follows addresses the procedures to be followed in
collecting, processing, analyzing and documenting evidence and specimens
that may be submitted as evidence in legal proceedings.

5.6.2. ***Physical Evidence***.

5.6.2.1. *Police and Security* must be contacted immediately to obtain
(collect or receive), process and establish custody of physical
evidence.

5.6.2.2. *VA Handbook 7030*, paragraph 8, provides guidance on
safeguarding evidence and property in the custody of Police.

5.6.2.3. *VA Form 3524*, Evidence or Property Custody Record (Attachment
A), and VA Form 3524a, Evidence or Property Tag, will be completed upon
the taking of either evidence or property into the custody of Police.

5.6.3. ***Biological Specimens***.

5.6.3.1. *General*. Daily operations in the Pathology and Laboratory
Medicine Service (P&LMS) do not routinely include chain-of-custody
documentation procedures. With the exception of pre-employment and
random employee drug screen testing, which includes strict
chain-of-custody procedures, testing is focused on patient care medical
needs and services. When the occasional request is made for clinical
testing information to be presented in a legal setting, the laboratories
rely upon documenting written standard operating procedures for unique
identification, collection, labeling, handling, processing, testing and
storing samples. All VAMC laboratories are required to maintain
accreditation through both the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) and the College of American
Pathologists (CAP). VAMC facilities with transfusion medicine services
also maintain accreditation through the American Association of Blood
Banks (AABB) and/or the Food and Drug Administration (FDA). Operational
guidelines for all Pathology and Laboratory Services are standardized
through adherence to the P&LMS Handbooks 1106.1 and 1106.2.

5.6.3.2. *Crime Scene*. In the event that collection of a biologic
specimen (such as blood, urine or tissue) is specifically declared part
of a crime scene investigation, chain-of-custody documentation must be
maintained throughout the collection, transport, testing, storage,
release and destruction phases. Biologic samples may be requested as
potential evidence in a biologic, chemical and radiological event in the
settings of terrorism, accidents and natural world occurrences.

5.6.3.3. *Forms*. The chain-of-custody form and the evidence form
provided by the Police or federal agent in charge of the incident must
accompany each unique sample from the time of sample collection to
delivery at the sample's final destination (testing site or repository).
According to the Centers for Disease Control (CDC), "Samples collected
from victims exposed to chemical agents are regarded as forensic, as
well as diagnostic, samples and must be handled as such. The name of
each person who has control of the sample must be documented throughout
the sample's existence." Laboratories should expect to document the
following steps in the chain-of-custody process and any ensuing
investigations:

-   Identity of individual collecting sample and method of collection
    (e.g. skin cleansing method; collection tube preservative; number of
    tubes collected; time and date of collection; and, sealing with
    evidence tape or seal, as appropriate).

-   Full name, social security number and date of birth of patient from
    whom the sample is collected; [or]{.underline} unique identifiers in
    the event that the patient is a "John or Jane Doe," if transmittal
    of information without name is required.

-   Transport and possession declarations for all steps from collection
    to storage or release and destruction.

-   Testing performed along with sampling methods (e.g., cap piercing
    versus cap removal) and testing methodologies.

-   Testing results along with documentation of testing dates; entry
    date and time; result verification process; and, linked information,
    such as comments and reference ranges.

-   Documentation of laboratory accreditation status and possible
    deposition of the laboratory director or testing technologists.

5.6.4. ***Environmental Samples***.

5.6.4.1. *Collecting Samples*. In the event of a biological, chemical or
radiological contamination event, it may be necessary to collect
environmental samples. Those samples may be a collection of residue
materials deposited in the area or air samples collected in the area
where the event occurred. Police and Security Service should be
contacted to witness the collection of samples, whenever possible, and
to ensure that the chain-of-custody procedures are maintained. An
important legal aspect of sampling and analysis is the documentation of
chain-of-custody. This is particularly the case when samples are
collected on-site and transferred to an analytical laboratory for
testing. Results may be challenged in court if a clear chain-of-custody
of the sample is not present.

5.6.4.2. *Labeling*. Chain-of-custody records are used to document the
location and personnel responsible for test samples. Samples must be
traced from the moment that the samples are taken to the time that the
final results are reported and the sample is archived or destroyed. This
involves tracking custody by the person collecting the sample until the
sample is relinquished; then tracking transport by courier or certified
delivery to the laboratory performing the analysis; and, finally,
tracking the chain of events within the laboratory leading to the
reporting of the results and the disposition of the sample. Custody
issues include:

> 1\. Individual or team collecting sample is responsible for:

-   The correct labeling of the sample.

-   Sealing of samples in a manner that allows tampering to be detected,
    should it occur.

-   Secure appropriate storage of samples in a controlled environment
    fit for the purpose.

> 2\. Transport via a courier or certified delivery service that
> provides:

-   The completion of shipping notes that include brief descriptions of
    the samples.

-   Maintenance of records containing dates/times of receipt and
    delivery, including names/signatures of personnel involved.

> 3\. Use of an accredited analytical laboratory that has:

-   An established accessioning program.

-   A chain of custody of samples program.

-   A documented quality assurance program.

5.6.4.3. *Identification of Samples*. Each sample must be assigned a
unique identification number. That unique identification number must be
documented on the sample label. A sample log is to be maintained that
includes the sample identification number, date of collection,
description of sample type, location of sample, sample analysis
requested and name of analytical laboratory.

5.6.4.4. *Sample Seals*. A supply of sample seals or evidence tape
should be readily available. Sample seals designed to clearly identify
tampering are available from most commercial accredited laboratories or
industrial hygiene supply vendors. Sample seals should be applied
immediately after collection by the person that collected the sample.

5.6.4.5. *Forms*. The easiest way to standardize the chain of custody of
test samples is to use a chain-of-custody form. The content of the forms
clearly identifies:

-   The name/address/telephone number of the customer.

-   Unique sample identifiers.

-   Instructions for the tests required upon the samples.

-   A section covering the actual chain-of-custody of the samples. This
    includes provision for stating the name of personnel, dates and
    times of relinquishment/receipt of the samples, etc.

A data sheet provided by the analytical laboratory, VA Form 10-0018 (Air
Sample Data Sheet) (Attachment B), or a chain-of-custody form designed
by the facility may be used to document chain of custody.

5.6.4.6. *Analytical Results*. The analytical laboratory must report the
chain of events within the laboratory leading to the reporting of the
results.

5.6.4.7. *Disposition of Sample*. Directions to the analytical
laboratory must include disposition of any evidence remaining after
analysis. Decisions on disposition of the sample will include
consideration of the stability of the sample, appropriateness of
retention and methods and location of storage. The laboratory must
provide information on the location and method of storage and the
procedures used to retrieve the sample, request additional analyses or
order the disposal of the remaining sample.

B. Sample Pharmacy Cache Readiness Plan

5.6.5. ***General***. VA treatment facilities will store a cache of
pharmaceuticals and medical supplies reserved specifically to treat
veterans, VA staff and victims seeking treatment at the VA facility that
are casualties from the use of Weapons of Mass Destruction (WMD).

-   The caches will be sized to treat either 1000 casualties (small
    cache) or 2000 casualties (large cache) for a two to three-day
    period.

-   The Under Secretary for Health will determine which size cache
    medical centers will receive and in what order. All VA treatment
    facilities will receive a cache on a scheduled basis.

-   The VA caches will be centrally purchased, configured and shipped to
    each VA facility by Pharmacy Benefits Management Strategic
    Healthcare Group (PBM).

-   Cache inventory will be centrally tracked. Replacement products will
    be centrally purchased and drop-shipped to each VA facility in
    advance of product expiration dates. A stock rotation program will
    be centrally managed by PBM.

-   Each VA facility will be responsible for cache inventory
    requirements and providing appropriate storage, security and
    accountability of the caches. Each VA facility will be responsible
    for assisting PBM with the stock rotation program.

-   Access to the cache will be limited, with details incorporated into
    the Emergency Operations Plan of VA treatment facilities.

-   The caches will be stored and secured in compliance with criteria
    issued by PBM.

-   PBM and Emergency Management Strategic Healthcare Group will provide
    training on all aspects of cache management and product use. The
    training will begin for each VA facility soon after it has been
    scheduled to receive a cache.

> A sample Standard Operating Procedure for the VHA Pharmaceutical Cache
> is contained in Section 6.3.3.6.

Attachments:

A. VA Form 3524, Evidence or Property Custody Record.

B. VA Form 10-0018, Air Sample Data Sheet.

Section 5 - Part 7

New FEMA (FPC 65) Requirements for VAMC Continuity of Operations Plans
(COOP)

5.7.1. ***Purpose*.** Federal Preparedness Circular 65 (FPC-65),
published by the Federal Emergency Management Agency (FEMA), now
requires all federal field facilities, including VA Medical Centers, to
have Continuity of Operations Plans (COOP). Community Based Outpatient
Clinics (CBOCs) do not require a COOP Plan. The purpose of this document
is to provide guidance to VA Medical Center (VAMC) staff on the
development of consistent and practical procedures for Continuity of
Operations (COOP). COOP planning is an effort to protect patients,
visitors and employees and assure that the capability exists to continue
essential VHA field functions across a wide range of potential
emergencies.

***"To meet this new requirement, all VAMCs need to modify their
existing Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) compliant Emergency Operations Plan to include the additional
FPC 65 requirements, as detailed in this section. A sample plan
accomplishing this task is provided in Section 4 (Enclosure 2) in this
Guidebook. Using this sample plan as a template will avoid the need for
the VAMC to write a separate stand-alone COOP plan."***

5.7.2 ***Background***. Continuity of Operations (COOP) planning began
in the 1950's because of the threat of a nuclear exchange between the
United States and Russia, and gained renewed visibility and importance
after the terrorist attack on the Pentagon on September 11, 2001. In
2002, FEMA integrated three pre-existing Federal Preparedness Circulars
(FPCs) and the resulting guidance - FPC #65 - was made mandatory for
Federal Executive Departments and Agencies. FPC #65 can be downloaded
at: <http://www.fema.gov/txt/library/fpc65_0604.txt>.

5.7.3. ***Applicability and Scope***. It is VHA policy that VAMCs and
other essential VHA facilities \[e.g., Consolidated Mail Outpatient
Pharmacies (CMOPs)\] must comply with the provisions of FPC #65. The
Emergency Management Committee will be responsible for determining the
extent of COOP planning within the organization.

5.7.4. ***Relationship to the Emergency Operations Plan (EOP)***. The
EOP explains the organization-wide strategy for response to and recovery
from any hazard, threat or event. It is structured around the management
functions of the Incident Command System (ICS). All COOP elements can be
organized within the EOP/ICS (e.g. the business continuity operational
function), or the organization can create a separate COOP plan as an
attachment.

5.7.5 ***Developing COOP Plans and Procedures***.

5.7.5.1. *Overall Process*. COOP planning should be integrated within
the nine-step process described in Section 3 of this Guidebook. The list
below illustrates which COOP elements relate to the various steps.

Step One - Functions of the Emergency Management Committee.

-   Orders of Succession

-   Delegation of Authority

Step Two - Developing the Emergency Operations Plan.

-   Devolution of Control and Management

-   Alternate Operating Facilities

-   Interoperable Communications

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-   Reconstitution

Step Four - Develop Incident-Specific Guidance

-   Identification of Essential Functions

-   Vital Records and Databases

-   Human Capital - Designation of Essential Staff; and, Development of
    Policies Covering Employee Leave During Emergencies

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-   Plans and Procedures (Service-Level and Overall Organization)

Step Seven - Provide Education and Training to Staff

-   Training

Step Eight - Implement the EOP

-   Tests and Exercises

The following information supports Step Four, Developing
Incident-Specific Guidance. Two levels of planning need to occur:
Service-Level and Organizational Level.

5.7.5.2. *Service-Level COOP Planning*. Each Service deemed essential by
the EMC should complete the following items:

5.7.5.2.1. *Functional Description*. Provide a description of the
Operating Unit's location and number of staff.

5.7.5.2.2. *Functional Responsibilities*. Provide a description of the
Operating Unit's mission, principal programs and responsibilities of key
staff.

5.7.5.2.3. *Requirements for Continuity of Operations*.

5.7.5.2.3.1. *Essential Operations.* List operations that must be
resumed as soon as possible to continue to provide benefits and services
after the COOP plan has been activated.

> Ranking: Highly Critical (**H**) - must continue uninterrupted or be
> re-established in the first 12 hours.
>
> Critical (**C**) - must be restored within the first 5 days.
>
> Important (**I**) - must be restored within 6 to 30 days.

+-------------+---------------------------+----------------------------+
| **Ranking** | **Operation**             | **Person Responsible**     |
|             |                           |                            |
| **H, C, I** |                           |                            |
+-------------+---------------------------+----------------------------+
| ( )         | (Operating Unit)          |                            |
+-------------+---------------------------+----------------------------+

5.7.5.2.3.2. *Essential Positions*. The following positions are
identified as being essential. Individuals assigned to essential
positions will be prepared to report to work or relocate on short notice
to an alternate operating facility, activate the site and carry out
essential operations for the duration of a declared emergency or
disaster.

+---------------+---------+----------------------+--------------------+
| **Office**    | *       | **Position**         | **Incumbent**      |
|               | *Site** |                      |                    |
|               |         |                      |                    |
|               | **(B    |                      |                    |
|               | ,C,H)** |                      |                    |
+===============+=========+======================+====================+
|               |         |                      |                    |
+---------------+---------+----------------------+--------------------+
|               |         |                      |                    |
+---------------+---------+----------------------+--------------------+
|               |         |                      |                    |
+---------------+---------+----------------------+--------------------+
|               |         |                      |                    |
+---------------+---------+----------------------+--------------------+
|               |         |                      |                    |
+---------------+---------+----------------------+--------------------+
|               |         |                      |                    |
+---------------+---------+----------------------+--------------------+
|               |         |                      |                    |
+---------------+---------+----------------------+--------------------+
|               |         |                      |                    |
+---------------+---------+----------------------+--------------------+

5.7.5.2.3.3. *Hardware Components* for Backup Site Operations*.*

  --------------------------- -------------------------------------------
  **Equipment Name**          **Remarks**

  PCs and Printers (number)   Network PCs required. Iomega Zip external
  assigned to (number)        Disk Drive -- backup essential documents.
  personnel                   Uninterrupted requirement

  FAX (number)                Uninterrupted requirement

  Phone (number)              Uninterrupted requirement

  Copier/Scanner              Uninterrupted requirement
  --------------------------- -------------------------------------------

5.7.5.2.3.4. *Software* for Backup Site Operations*.*

  ------------------------------- --------- -------------------------------
  **Item**                        **Qty**   **Remarks**

  Microsoft Office 2000                     

  MS Outlook Exchange                       

  Travel Accounting                         

  Internet Explorer 6.0                     

  Terminal Emulation Software               
  ------------------------------- --------- -------------------------------

5.7.5.2.3.5. *Communication Components* for Backup Site Operations*.*

  -------------------------------------- --------------------------------
  **Equipment Name**                     **Remarks**

  Interface to VANTS                     XX line - uninterrupted
                                         requirement

  Connectivity to email WAN              PC's (XX) - uninterrupted
                                         requirement

  Phone lines                            XX lines - uninterrupted
                                         requirement
  -------------------------------------- --------------------------------

5.7.5.2.3.6. V*ital Records* for Backup Site Operations*.*

  -------------------------------------- --------------------------------
  **Vital Record Name**                  **Remarks**

                                         

                                         

                                         

                                         

                                         

                                         
  -------------------------------------- --------------------------------

### 

5.7.5.2.3.7. *Materiel* for Backup Site Operations. Documentation,
Supplies and Forms.

  ------------------- ----------------------- --------- ---------------------
  **Item**            **Description**         **Qty**   **Remarks**

  Disks                                                 Uninterrupted
                                                        requirement

  File folders                                          Uninterrupted
                                                        requirement

  Pens/pencils                                          Uninterrupted
                                                        requirement

  Copier paper                                          Uninterrupted
                                                        requirement

  Standard tablets                                      Uninterrupted
  (lined)                                               requirement
  ------------------- ----------------------- --------- ---------------------

5.7.5.3. *Organizational-Level COOP Planning*. The following information
was adapted from the FEMA Continuity of Operations (COOP) Planning
Template.

5.7.5.3.1. [Executive Summary]{.underline}. The executive summary should
briefly outline the organization and content of the COOP Plan; and
describe what it is, whom it affects, and the circumstances under which
it should be executed. Further, it should discuss the key elements of
COOP planning, and explain the organization's implementation strategies.

5.7.5.3.2. [Introduction]{.underline}. The introduction to the COOP Plan
should explain the importance of COOP planning to the organization. It
may also discuss the background for planning, referencing recent events
that have led to the increased emphasis on the importance of a COOP
capability for the organization.

Sample: Planning for COOP activation is a good business practice \--
part of the fundamental mission of VHA as a responsible and reliable
public institution. The changing threat environment and recent
emergencies, including localized acts of nature, accidents,
technological emergencies or terrorist attack-related incidents, have
shifted awareness to the need for COOP capabilities that enable VHA to
continue essential functions across a broad spectrum of emergencies.
Also, the potential for terrorists' use of weapons of mass destruction
has emphasized the need to develop a plan that ensures continuity of
essential VHA functions.

5.7.5.3.3 [Purpose]{.underline}. The purpose paragraph should explain
why the organization is developing a COOP Plan. It should briefly
discuss applicable Federal guidance and explain the overall purpose of
COOP planning, which is to ensure the continuity of mission essential
functions. Because of today's changing threat environment, this section
should state that the COOP Plan is designed to address the all hazard
threat.

Sample: COOP planning is an effort to protect patients, visitors and
employees and assure that the capability exists to continue essential
VHA field functions across a wide range of potential emergencies. COOP
objectives include:

a\. Preventing and/or reducing loss of life and serious injury.

b\. Protecting essential facilities, equipment, records and other
assets.

c\. Ensuring the continuous performance of VAMC essential
functions/operations during an emergency.

d\. Ensuring that the VAMC has alternate care sites to ensure continuity
of patient care and facilities from which it can continue to perform
essential functions during an emergency.

e\. Executing, as required, succession to office with accompanying
authorities in the event a disruption renders agency leadership unable,
unavailable or incapable of assuming and performing their authorities
and responsibilities of offices.

f\. Ensuring and validating COOP readiness through a dynamic, integrated
test, training and exercise program to support the implementation of the
COOP Plan.

5.7.5.3.4. [Applicability and Scope]{.underline}. This section describes
the applicability of the plan to the organization as a whole; main
facility as well as subordinate activities, co-located and
geographically dispersed; and to specific personnel groups of the
organization. It should also include the scope of the plan. Ideally,
plans should address the full spectrum of potential threats, crises and
emergencies (natural as well as man-made).

Sample: It is VHA policy that VAMCs and other essential VHA facilities
(e.g., Consolidated Mail Outpatient Pharmacies) must comply with the
provisions of FPC #65. The Emergency Management Committee will be
responsible for determining the extent of COOP planning within the
organization.

5.7.5.3.5 [Essential Functions]{.underline}. The essential functions
section should include a list of the organization's prioritized
essential functions. Essential functions are those organizational
functions and activities that must be continued under any and all
circumstances.

Organizations should:

-   Identify all functions; then, determine which must be continued
    under all circumstances.

-   Prioritize these essential functions.

-   Establish staffing and resource requirements.

-   Integrate supporting activities.

-   Develop a plan to perform additional functions as the situation
    permits.

Sample: The Emergency Management Committee, after reviewing all of the
Key Operating Unit COOP Templates, will establish a list of essential
functions for the organization.

**Sample**

  -----------------------------------------------------------------------
  **Priority**     **Essential Functions**
  ---------------- ------------------------------------------------------
  1                Provide healthcare services.

  2                Ensure the safety of patients, visitors and staff.

  3                Protect legal and financial records.

  4                Maintain documentation necessary for reconstitution.

  5                **Support requests for assistance by the community.**

                   (Modify list as needed to meet the needs of VAMC)
  -----------------------------------------------------------------------

5.7.5.3.6 [Authorities and References]{.underline}.

Sample:

a\. The National Security Act of 1947, dated July 26, 1947, as amended.

b\. Executive Order 12148, Federal Emergency Management, dated July 20,
1979, as amended.

c\. Executive Order 12472, Assignment of National Security and Emergency
Preparedness Telecommunications Functions, dated April 3, 1984.

d\. Executive Order 12656, Assignment of Emergency Preparedness
Responsibilities, dated November 18, 1988, as amended.

e\. Federal Preparedness Circular 60, Continuity of the Executive Branch
of the Federal Government at the Headquarters Level During National
Security Emergencies, dated November 20, 1990.

f\. VHA Directive 0320, Emergency Medical Preparedness, May 1, 1997.

g\. Presidential Decision Directive 62, Protection Against
Unconventional Threats to the Homeland and Americans Overseas, dated May
22, 1998.

h\. Presidential Decision Directive 63, Critical Infrastructure
Protection, dated May 22, 1998.

i\. Homeland Security Presidential Directive 3, Homeland Security
Advisory System, dated March 11, 2002.

j\. Homeland Security Presidential Directive 5, Management of Domestic
Incidents, dated February 28, 2003.

k\. Homeland Security Presidential Directive 7, Critical Infrastructure
Identification, Prioritization, and Protection, dated December 17, 2003.

l\. Homeland Security Presidential Directive 8, National Preparedness,
dated December 17, 2003.

m\. 41 CFR 101-2, Occupant Emergency Program, revised July 1, 1998.

n\. 36 CFR 1236, Management of Vital Records, revised as of July 1,
1998.

o\. Presidential Decision Directive 67, Enduring Constitutional
Government and Continuity of Government Operations, dated October 21,
1998.

p\. Federal Preparedness Circular 65, dated June 15, 2004.

q\. VA Directive 0320, Emergency Medical Preparedness, dated October 18,
1999.

r\. VA Handbook 0320, Emergency Preparedness Planning Procedures and
Operational Requirements, dated October 18, 1999.

s\. Executive Order 13247, Providing an Order of Succession Within the
Department of Veterans Affairs, dated December 18, 2001.

5.7.5.3.7. [Concept of Operations]{.underline}. This section should
explain how the organization will implement its COOP Plan and,
specifically, how it plans to address each critical COOP element. This
section should be separated into three phases: Activation and
Relocation, Alternate Care Site Operations and Reconstitution. The
Incident Command System (ICS) will be used to plan, organize, staff,
direct and control emergency situations.

*Phase I: Activation and Relocation.* The Phase I section should explain
COOP Plan activation procedures and relocation procedures from the
primary facility to the alternate care sites. This section should also
address procedures and guidance for non-relocating personnel.

[Decision Process]{.underline}. This section should explain the logical
steps associated with implementing a COOP Plan, the circumstances under
which a plan may be activated (both with and without warning), and
should identify who has the authority to activate the COOP Plan. This
process can be described here or depicted in a graphical representation.

[Alert, Notification and Implementation Process]{.underline}. This
section should explain the events following a decision to activate the
COOP Plan. This includes employee alert and notification procedures and
the COOP Plan implementation process.

Sample:

COOP procedures would be activated in response to situations when all or
part of the VAMC is unavailable, and operations must be relocated to an
alternate location.

***Phase I: Activation and Relocation (0-12 Hours)***. In this phase,
the following actions will be taken:

-   Initial notifications, activation and procedures would be issued by
    the Office of the Director who will notify VISN leadership of
    impending activation and actual relocation requirements.

-   Activate VAMC plans, procedures and schedules to transfer
    activities, personnel, records and equipment to alternate care site.

-   Notify VAMC Key Operating Unit Managers to relocate.

-   Notify all other VAMC employees to await further instructions.
    Employees at home will be available by phone during all assigned
    work hours.

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-   Begin essential operations at the alternate location (within 12
    hours).

***Phase II: Alternate Site Operations (12 Hours to Termination)***.

-   Provide guidance to other key staff and employees not at the
    alternate care site(s).

-   Identify replacements for missing personnel, and obtain additional
    support as needed.

-   Commence full execution of essential operations at the alternate
    site(s).

-   Notify VHA Central Office and other agencies of operational and
    communications status and anticipated duration of relocation, if
    known.

-   Develop plans and schedules to phase down the alternate site(s)
    operations, and return activities, personnel, records and equipment
    to the primary facility as appropriate.

-   Mission-Critical Systems - Depending on the type of emergency
    situation encountered, multiple mission-critical systems may be
    affected and could include such events as loss of power,
    communications, utilities, etc.

***Phase III: Reconstitution (Terminate COOP and Return to Normal
Operations)***.

-   Inform all VAMC personnel that the threat of an emergency or the
    actual emergency no longer exists, and provide instructions for
    resumption of normal operations.

-   Begin orderly return to VAMC or movement to other temporary or
    permanent facilities.

-   Report status of relocation to VHA Central Office and other
    agencies, as appropriate.

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-   Conduct an after-action review of VAMC COOP operations and evaluate
    effectiveness of plans and procedures as soon as possible. Identify
    areas for correction, and develop a remedial action plan as needed.

5.7.5.3.8. [Orders of Succession]{.underline}. This section should
identify orders of succession to key positions within the organization.
Orders should be of sufficient depth to ensure the organization's
ability to manage and direct its essential functions and operations. The
conditions under which succession will take place, the method of
notification and any temporary, geographical or organizational
limitations of authority should also be identified in this section.

Sample:

  -----------------------------------------------------------------------
  **Successors**
  -----------------------------------------------------------------------
  Director

  Associate Director

  Chief of Staff

  Associate Director for Patient Care Services
  -----------------------------------------------------------------------

5.7.5.3.9 [Delegations of Authority]{.underline}. This section should
identify, by position, the authorities for making policy determinations
and decisions at Headquarters, field levels and other organizational
locations, as appropriate. Generally, pre-determined delegations of
authority will take effect when normal channels of direction are
disrupted, and terminate when these channels have resumed. Such
delegations may also be used to address specific competency requirements
related to one or more essential functions that are not otherwise
satisfied by the order of succession. Delegations of authority should
document the legal authority for making key decisions, identify the
programs and administrative authorities needed for effective operations,
and establish capabilities to restore authorities upon termination of
the event. Pre-determined delegations of authority may be particularly
important in a devolution scenario.

Sample: The VHA Central Office COOP plan defines authorities for making
policy determinations and decisions at Headquarters, field levels and
other organizational locations, as appropriate, including:

-   Identification of the programs and administrative authorities needed
    for effective operations at all levels of VHA during an emergency.

-   Documentation of the necessary authorities at all points where
    emergency actions may be required.

-   Documentation to ensure that officials who may be expected to assume
    authorities in an emergency are trained to carry out their emergency
    duties.

In addition to the authorities not already delegated to the Key
Operating Unit Managers by virtue of their regular positions within the
VAMC, all of the authorities of the Director are hereby delegated to the
Deputy Director/Associate Director and/or the Chief Medical Director
Officer/Chief of Staff. The authorities may not be re-delegated.

The authorities delegated by this Plan are to be exercised only in the
case of emergencies and only in cases where the Director is unavailable
or unable to perform the duties of that Office. These authorities may be
exercised by the alternates named above, as they are available and able
and in the order in which they are listed, until such time as the
Director is available to exercise such authorities.

To the extent that there are authorities of the Director that by law or
regulation may not be re-delegated to the named alternates, such
limitations will be identified in the VHA Central Office COOP Plan. This
Plan shall remain in effect until its provisions are amended, superseded
or revoked, whichever occurs first.

5.7.5.3.10. [Devolution]{.underline}. The devolution section should
address how an organization will identify and conduct its essential
functions in the aftermath of a worst-case scenario, one in which the
leadership is incapacitated. The organization should be prepared to
transfer all of their essential functions and responsibilities to
personnel at a different office or location. Sample:

-   *Director* - Responsible for leadership and direction of the VAMC
    and for interfacing with the VISN Director and other VHA
    organizations. The Director is responsible for ensuring that the
    VAMC has a functional COOP plan that is integrated with the overall
    VISN EOP. The Director is also responsible for ensuring all VAMC
    staff are trained on their responsibilities in the plan.

-   *Associate Director* - Serves as the point of contact with other
    offices inside and outside of the VAMC and acts in place of the
    Director.

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-   *Chief of Staff* - Responsible for advising on clinical issues
    related to the emergency and acts on behalf of the Director or
    Associate Director.

-   *Chief, Fiscal Service* - Responsible for advising on financial
    issues as they relate to the emergency.

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-   *Key Operating Unit Managers* - Responsible for identifying
    essential functions for their offices. They are also responsible for
    identifying employees who would relocate to alternate care sites
    and/or work from home. They must secure vital equipment, records and
    other key assets as required to carry out the essential functions.
    They also must ensure that all employees are trained on their
    responsibilities in the COOP plan.

-   *ALL VAMC Staff*:

1)  Maintain normal operating procedures to the best of their ability.

2)  Notify VAMC Security or facility operator of any disturbance or
    emergency (i.e., fire, bomb threat, external community disaster,
    etc.) that may affect VAMC.

3)  Immediately check for injuries among staff and offer assistance, as
    practical. Seriously injured persons should not be moved unless they
    are in danger of further injury.

4)  In the event of fatalities, area staff should cover the bodies and
    report the situation to a Staff Director as soon as possible.

5)  Secure/protect records and other official files.

5.7.5.3.11. [Vital Files, Records and Databases]{.underline}. This
section should address the organization's vital files, records and
databases necessary to perform essential functions and activities and to
reconstitute normal operations after the emergency ceases (this includes
classified or sensitive data). Organizational elements should
pre-position and update on a regular basis those duplicate records,
databases or back-up electronic media necessary for operations. Sample:
These are detailed in the Key Operating Unit COOP Templates.

5.7.5.3.12. [Logistics]{.underline}.

5.7.5.3.12.1. Alternate Care Site. The alternate care site section
should explain the significance of identifying an alternate care site,
the requirements for determining an alternate care site, and the
advantages and disadvantages of each location. Senior managers should
take into consideration the operational risk associated with each
facility. Performance of a risk assessment is vital in determining which
alternate care site will best satisfy an organization's requirements.

Sample: This VAMC is a medical hospital, providing medical services on a
continuous basis (24/7); as such, services will not relocate to an
alternate facility during an emergency. However, should conditions
warrant evacuation, patients will be moved to a proximal VA facility or
community facility for continued care in compliance with alternate care
site plans and procedures.

Alternate facilities should provide:

-   Sufficient space and equipment.

-   Capability to perform essential functions within 12 hours up to 30
    days.

-   Reliable logistical support, services and infrastructure systems.

-   Consideration for health, safety and emotional well-being of
    personnel.

-   Interoperable communications.

-   Computer equipment and software.

5.7.5.3.12.2. Interoperable Communications. The interoperable
communications section should identify available and redundant critical
communication systems that are located at the alternate facility. These
systems should provide the ability to communicate within the
organization and outside the organization.

Interoperable communications should provide:

-   Capability commensurate with an agency's essential functions.

-   Ability to communicate with essential personnel.

-   Ability to communicate with other agencies, organizations and
    customers.

-   Access to data and systems.

-   Communications systems for use in situations with and without
    warning.

-   Ability to support COOP operational requirements.

-   Ability to operate at the alternate facility within 12 hours and for
    up to 30 days.

-   Interoperability with existing field infrastructures.

Sample: VAMC maintains communications within the facility by cell phone,
pagers and hand-held walkie-talkies. Interoperable communications are
available through e-mail, GETS cards and satellite telephones.

5.7.5.3.13. [Test, Training and Exercises]{.underline}. This section
should address the organization's Test, Training and Exercise (TT&E)
Plan. Tests, training and exercises familiarize staff members with their
roles and responsibilities during an emergency, ensure that systems and
equipment are maintained in a constant state of readiness, and validate
certain aspects of the COOP Plan. Managers may be creative when it comes
to COOP readiness and include snow days, power outages, server crashes
and other ad-hoc opportunities to assess preparedness.

COOP Test, Training and Exercise Plans should provide:

-   Individual and team training of personnel.

-   Internal agency testing and exercising of COOP plans and procedures.

-   Testing of alert and notification procedures.

-   Refresher orientation for COOP personnel.

-   Joint interagency exercising of COOP plans, if appropriate.

Sample: VAMCs should include COOP in its on-going training and exercise
program. VAMCs should conduct an exercise at least semi-annually,
including a semi-annual exercise with the community. Additional
information on education, training and exercise programs are described
in Section 9. Records of this training must be maintained. Staff shall:

-   Be trained on the Emergency Operations Plan, this COOP plan and any
    functions that relate to their Operating Unit.

-   Be familiar with basic fire, Hazardous Materials (HAZMAT) and other
    emergency responses.

-   Participate in training and exercises. These exercises are intended
    to practice emergency response activities and improve readiness.

5.7.5.3.14. [Plan Maintenance]{.underline}. This COOP plan will be
evaluated periodically and revised as needed.

5.7.5.3.15. [Annexes]{.underline}.

Annex A - Authorities and References. See paragraph (*insert applicable
paragraph number from Plan*) above.

Annex B - Operational Checklist. See Attachment XX *(see Section 4,
Enclosure 2, Attachment C for sample).*

Annex C - Alternate Location/Facility Information. See paragraph
*(insert applicable paragraph number from Plan)* above.

Annex D - Maps and Evacuation Routes. N/A

Annex E - Definitions and Acronyms. See Section 1, Emergency Management
Program Guidebook.