091406 Pan Flu IC Tabletop

San Francisco Pandemic Influenza Infection Control Table Top Exercise: 

San Francisco Pandemic Influenza Infection Control Table Top Exercise San Francisco Department of Public Health Communicable Disease Control & Prevention Section San Francisco, California September 14, 2006

Slide2: 

WELCOME & INTRODUCTIONS

Acknowledgement – Pan Flu Tabletop Task Force Members: 

Acknowledgement – Pan Flu Tabletop Task Force Members Barbara DeBaun (CPMC/St. Luke’s) Mark Donnell (CPMC/St. Luke’s) Jonathan Garber (VA) Roger Gillespie (Kaiser) Yeva Johnson (SFDPH) Pancy Leung (SFDPH) Lilia Ryan (SFGH) Anthony Valentine (CMPC/St. Luke’s) Lann Wilder (SFGH)

Agenda: 

Agenda 8:25-8:35 Review objectives, format and Ground Rules 8:35-10:05 Discuss scenario 10:05-10:20 Break 10:20-11:15 Scenario continues 11:15-11:30 (Hospital) Hot Wash 11:30-11:55 (Group) Hot Wash 11:55-12:00 Evaluation

Goal of the Tabletop Exercise: 

Goal of the Tabletop Exercise To practice coordination and communication activities in a pandemic influenza scenario among Hospital Infection Control Professionals, Hospital Emergency Preparedness Coordinators, and Sections of the San Francisco Department of Public Health (SF DPH).

Objectives: 

Objectives 1. Identify thresholds that would trigger an emergency response activation or a change in infection control standards within each hospital before and during an influenza pandemic. 2. Improve communication between emergency preparedness coordinators and infection control professionals as they prepare for hospital infectious disease emergency responses.

Ground Rules: 

Ground Rules During the scenario, participate in the role that you would fill during daily operations and/or when a pandemic occurs Using the documents and materials provided (as well as the ones you brought), discuss the scenarios from the point of view of your hospital, assuming each scenario is at your hospital Print any questions you have for SFDPH on the index cards provided and hold them up so that they can be collected

Ground Rules Continued: 

Ground Rules Continued Today’s scenarios encompass multiple complex issues that may occur during a pandemic, please focus on today’s questions and don’t get side tracked We’ll have small and large group discussions, so please follow instructions There are no right or wrong answers Observers and Evaluators may not participate in any of the discussions

Ground Rules Continued: 

Ground Rules Continued Each hospital will receive an individual report from your respective Evaluators The After Action Report from this exercise will contain aggregate data only; individual hospitals will not be identified. Please be candid!

Slide10: 

Let’s Play…

Background: 

Background It is February 2007, WHO reports ongoing avian influenza (H5N1) outbreaks in Asian, European, and African countries. There is no efficient human-to-human transmission, and the alert level remains at Pandemic Alert Phase 3.

Scenario A: 

Scenario A On Feb. 14th , 2007 at 4 p.m., the Emergency Department (ED) nurse calls the Infection Control Professional (ICP) and states that there is a patient in the ED waiting to be admitted with a diagnosis of rule out H5N1 Avian Influenza.

Scenario A Questions: 

Scenario A Questions What does the ICP do? Should the ICP or anyone else contact the Emergency Preparedness Coordinator (EPC)? Do you need additional information to guide your decisions/actions? If so, where will you find it? Who will you (ICP and EPC) consult and/or notify within the hospital? Outside of the hospital?

Slide14: 

5 minutes left

Slide15: 

1 minute left, Please wrap up discussion

Scenario A Slide #2: 

Scenario A Slide #2 The ICP calls SFDPH and specimens are sent from your hospital and arrive at the Public Health Lab on Feb. 15th at 10a.m. At 4 p.m., the preliminary test is positive for influenza A and equivocal for sub-type H3. The specimens are forwarded to the State lab for additional testing. By noon on Feb. 16th, the State lab confirms seasonal influenza and no avian influenza. The patient improves on antivirals and is discharged home after 4 days.

Scenario B: 

Scenario B On Monday, September 8th, 2008, WHO reports evidence of increased human to human transmission of H5N1 avian influenza in both Indonesia and China. Many of the cases were reported late as both countries’ public health systems are overwhelmed by the numbers of avian and human cases. WHO raises the alert level to Pandemic Alert Phase 4 and the SFDPH sends out a Health Alert.

Scenario B Slide #2: 

Scenario B Slide #2 San Francisco DPH Health Alert #1

Implications for Pandemic Alert Phase 4: 

Implications for Pandemic Alert Phase 4 Please keep in mind as you answer the next questions… H5N1 virus is now transmissible from person to person Infection Control precautions are the only means of protection until a vaccine is developed or antivirals are shown to be effective

Scenario B Slide #3: 

Scenario B Slide #3 On Tuesday, Nov. 4th at 10 p.m., Mr. Yu, a visiting Chinese national goes to Chinese Hospital ED with flu-like symptoms which started on Nov. 2nd. He arrived 5 days ago (Fri., Oct. 31st) from Beijing with his family to visit relatives who live in Chinatown. His cousin Mr. Chen, a native San Franciscan, accompanies Mr. & Mrs. Yu to the hospital. Census at Chinese Hospital is at about 85% capacity. All but one negative pressure airborne isolation rooms are being used for TB patients.

Scenario B Slide #4: 

Scenario B Slide #4 Mr. Yu is a 42 year old businessman who travels frequently to the southern part of China. He denies having TB, but said he was given a 6-month course of medication when his father had TB 2 years ago. On physical exam, he has a temperature of 101.6ºF, productive cough, Shortness of Breath, Chest XRay shows right upper and lower lobe infiltrates, Oxygen saturation is 88%. Mr. Yu is admitted to Chinese Hospital on Nov. 5th at 2 a.m.

Scenario B Slide #5: 

Scenario B Slide #5 Having remembered the SFDPH Health Alert, the ED physician considers Avian Influenza in the differential diagnosis and calls the ICP who also calls the SF DPH Communicable Disease Control Unit at (554-2830) and the hospital’s Emergency Preparedness Coordinator. The specimens - N/P (nasopharyngeal) and throat swabs are picked up on the afternoon of Nov. 5th to be sent to the Public Health Lab.

Scenario B Slide #6: 

Scenario B Slide #6 On Thursday, Nov. 6th at 8:30a.m., preliminary results from SFDPH lab are positive for H5N1, and the specimens are sent on to the State public health lab for confirmation. SFDPH and the Mayor’s office hold a press conference at 10am to announce the first human case of H5N1 in San Francisco.

Scenario B Questions (Part 1): 

Scenario B Questions (Part 1) What is your isolation procedure? What is the mechanism in your hospital to identify clinical and support staff who have been exposed? What do you tell your exposed staff? Who would you notify about the H5N1 result? What information would you give to the general staff at this point? What questions do you have for SFDPH? If any. How would you manage this patient differently from the patient in Scenario A?

Slide25: 

5 minutes left

Slide26: 

1 minute left, Please wrap up discussion

Scenario B Slide #7: 

Scenario B Slide #7 Mr. Yu’s condition deteriorates the night of Nov. 6th. He requires intubation. All ICU beds at Chinese Hospital are occupied, so he is transferred to UCSF Medical Center. That evening at 11pm., SFDPH receives confirmation from the State lab that Mr. Yu’s specimen tested positive for H5N1.

Scenario B Slide #8: 

Scenario B Slide #8 The next afternoon (Nov. 7th), the CA state public health lab confirms a second human case of H5N1 in Alameda County and notifies all the local health departments. SFDPH has activated its Infectious Disease Emergency Response Plan, and is actively investigating possible cases and contacts, and instituting Isolation and Quarantine measures.

Scenario B Group Questions (Part 2): 

Scenario B Group Questions (Part 2) Will your hospital activate your emergency response plan? Who will make that decision? What information do you need to make that decision? What do you tell your staff? How do you triage the influx of patients who will come to the hospital?

Scenario B Slide #9: 

Scenario B Slide #9 When Mrs. Yu visits her husband in the ICU on that Friday, Nov. 7th, she appears tired and has a hacking cough. She attributes her symptoms to lack of sleep. SF DPH recommends isolation for Mrs. Yu who is admitted that same day to SFGH because there is an airborne isolation room available. The Yu children and the Chen family are quarantined at the Chen’s home, also on Nov. 7th . Mr. Yu passes away on the afternoon of Sunday, Nov. 9th. The news of Mr. Yu’s death travels quickly in and out of Chinese Hospital, UCSF, and SFGH.

Scenario B Slide #10: 

Scenario B Slide #10 Ever since the Nov. 7th Press Conference confirming the first human case of H5N1, masks and gloves have been disappearing from hospital stock rooms. Your Materials Management Director tells you on Mon. Nov. 10th that he only has enough masks and gloves to meet 60% of the anticipated need for the next 2 days until the next shipment arrives on Wednesday.

Scenario B Group Questions (Part 3): 

Scenario B Group Questions (Part 3) What do you tell the staff about PPE? How will you enforce it? Do you have a stockpile of PPE? If yes… What’s in it? Where is it? How long will it last? When will you draw from it? Who decides? How will you distribute/utilize it? If no… What will you do? Do you consider modifying your infection control guidelines?

Scenario B slide #11: 

Scenario B slide #11 Globally, there were only 7 small clusters of localized H5N1 cases, and all of them were contained. Large clusters never developed and there are no additional human clusters by March 2009, although sporadic poultry outbreaks continue. WHO downgrades the alert level back to Pandemic Alert Phase 3.

Slide34: 

Take a break

Slide35: 

5 minutes left

Slide36: 

Let’s continue…

Scenario C: 

Scenario C On Monday, June 1st, 2009, St. Mary’s Medical Center reports 2 suspect cases of H5N1; the VA reports 3 cases and CPMC reports 5 cases (2 from St. Luke’s) to SFDPH. Preliminary tests come back positive for H5 strain of influenza. SF DPH recommends continuing vigilant respiratory and hand hygiene for all persons with influenza-like illness and institutes contact tracing and airborne isolation for suspect cases.

Scenario C Slide #2: 

Scenario C Slide #2 The next day (Tues. June 2nd ), SFDPH receives more reports of suspect cases from: Kaiser (4), St. Francis (2), St. Mary’s (1), SFGH (5), UCSF (6). By 10 a.m. on Tuesday, confirmatory tests from the State lab identify H5N3 from the June 1st specimens.

Scenario C Slide #3: 

Scenario C Slide #3 SF DPH sends an urgent message on June 2nd to all hospitals requesting ICPs to participate in a telephone conference call on June 3rd at 9a.m. The agenda is as follows: Update from SF DPH on the number of lab confirmed cases of H5N3 Update from hospitals on the status of Infection Control supplies Future Communication – the CDCP website (www.sfdph.org/cdcp) will be updated at least daily, fax alerts, and phone conferences as SF DPH able.

Scenario C Group Question (Part 1): 

Scenario C Group Question (Part 1) This is the June 3rd , 9am Telephone Conference call: What additional items would you like to have on the agenda for this type of conference call? What other questions do you have for SF DPH?

Scenario C Slide #4: 

Scenario C Slide #4 On June 3rd, at 2 p.m., WHO reports a new influenza strain has broken out in clusters in many cities in Asia, Africa, and elsewhere. It is believed to be a mutated H5N3 strain that is efficient in its transmission from person-to-person. WHO raises the alert level to Pandemic Phase 6.

Scenario C Slide #5: 

Scenario C Slide #5 Your hospital has patients waiting in the ED, on Friday, June 5th, at 35% above your capacity. 60% of the staff report to work. Supplies are dwindling and you have been only getting intermittent shipments as some truckers are afraid to drive up to the hospital for fear of getting the disease.

Scenario C Questions (Part 2): 

Scenario C Questions (Part 2) What are your hospital’s infection control recommendations at this time given the shortages of PPE and lack of isolation rooms? What about staffing issues? Who’s going to do your job when you go home? Do you have a plan to address staff shortages? If so, how will you implement it in this scenario? Who makes the decisions about how to handle the shortages? How will it be enforced?

Slide44: 

10 minutes left

Slide45: 

5 minutes left

Slide46: 

1 minute left, Please wrap up discussion

Scenario C Slide #6: 

Scenario C Slide #6 On Wed. June 24th, 2009, being the conscientious person you are, you report to work. Your Incident Commander briefs you: all ventilators are in use, there are no more N95 masks, surgical mask supplies are inadequate, soap and paper towels are drying up, staff report getting sick at work the hospital is not expecting to receive shipments of supplies anytime soon.

Scenario C Group Question (Part 3): 

Scenario C Group Question (Part 3) What do you do at this point? What planning and preparations should we make NOW to minimize the impact of this type of situation?

Hospital Hot Wash: 

Hospital Hot Wash Evaluators have 15 min. to go over questions with you now.

Slide50: 

5 minutes left

Slide51: 

1 minute left, Please wrap up discussion

Group Hot Wash: 

Group Hot Wash What are your thoughts??? About the exercise? About your institution’s level of infection control preparedness? Any other thoughts?

Evaluation: 

Evaluation Please complete the evaluation form in your folder and drop it off at the back of the room and pick up a complete copy of the exercise scenario.

Slide54: 

THANK YOU FOR YOUR PARTICIPATION!