Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science Volume 12, Number 2, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/bsp.2013.0089

The Planning, Execution, and Evaluation of a Mass Prophylaxis Full-Scale Exercise in Cook County, IL Andy Kilianski, Amy T. O’Rourke, Crystal L. Carlson, Shannon M. Parikh, and Frankie Shipman-Amuwo

Increasing threats of bioterrorism and the emergence of novel disease agents, including the recent international outbreaks of H7N9 influenza and MERS-CoV, have stressed the importance and highlighted the need for public health preparedness at local, regional, and national levels. To test plans that were developed for mass prophylaxis scenarios, in April 2013 the Cook Country Department of Public Health (CCDPH) and the Triple Community (TripCom) Medical Reserve Corps (MRC) executed a full-scale mass prophylaxis exercise in response to a simulated anthrax bioterrorism attack. The exercise took place over 2 days and included the TripCom Point-of-Dispensing (POD) Management Team, volunteers from the TripCom MRC, and neighboring public health departments and MRCs. Individuals from the community volunteered as actors during the exercise, while local municipal, police, and fire personnel coordinated their responses to create the most realistic simulation possible. The exercise was designed to test the capacity of TripCom and CCDPH to implement plans for organizing municipal staff and volunteers to efficiently distribute prophylaxis to the community. Based on results from POD clinic flow, accuracy of prophylaxis distribution, and observations from evaluators, the exercise was successful in demonstrating areas that were operationally efficient as well as identifying areas that can be improved on. These include improvements to the just-in-time training for POD staff, the health screening and consent forms handed out to patients, the physical setup of the POD, and the command structure and communication for the management of POD operations. This article demonstrates the need for full-scale exercises and identifies gaps in POD planning that can be integrated into future plans, exercises, and emergency response.

I

ncreasing threats of bioterrorism and the emergence of novel disease agents have stressed the importance and highlighted the need for public health preparedness at local, regional, and national levels.1 Further, the identification of novel viral agents like MERS-CoV and H7N9 influenza that have the potential to emerge from animal reservoirs and infect humans is a major public health is-

sue.2,3 Immunizations and antiviral drugs are being developed and tested against these pathogens, and if these viruses or future emergent viruses were to become pandemic and be transmitted to the United States, systems must be in place to administer either vaccines or antivirals to susceptible individuals.3,4 These recent outbreaks, taken with the continued threat of bioterrorism from either foreign or

Andy Kilianski, PhD, is National Research Council Fellow, BioSciences Division, Edgewood Chemical and Biological Center, Aberdeen Proving Ground, Edgewood, Maryland. Amy T. O’Rourke, MPH, MEP, is Emergency Response Coordinator; Crystal L. Carlson, MPH, MEP, is Emergency Response Coordinator and Interim MRC Coordinator; and Frankie Shipman-Amuwo, MPH, is Interim Director; all in the Emergency Preparedness and Response Unit, Cook County Department of Public Health, Oak Forest, Illinois. Shannon M. Parikh, JD, MPH, is Manager of Regulatory and Safety Compliance, Department of Accreditation and Regulatory Compliance, Sinai Health System, Chicago, Illinois. 106

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domestic entities, highlight the importance of detailed planning and execution of training exercises designed to dispense prophylactic medication to a local population.1,5-7 In the event of a bioterrorism attack or communicable disease outbreak, mass prophylaxis is one of the most critical response mechanisms and is a major focus of public health preparedness and funding.8 As part of the Cook County (IL) Department of Public Health’s (CCDPH) mass prophylaxis planning, the medication that arrives to assist suburban Cook County will be given out at points of dispensing (PODs). The goal of a POD is to distribute medication to affected people quickly and safely to prevent further illness and protect the local population. The CCDPH has identified PODs that are strategically located throughout suburban Cook County to serve as the primary locations for dispensing prophylaxis to the local residents. To enhance preparedness and test the ability of the CCDPH to coordinate a mass prophylaxis operation, we detail in this article the strategy, planning, execution, and evaluation of a full-scale exercise in response to a simulated anthrax bioterrorism attack. The goal is to detail how CCDPH works with local communities to design and exercise POD operations, to outline the execution of the fullscale exercise, and to describe the lessons learned by CCDPH on how to improve POD operations in suburban Cook County and how those lessons can be applied in the future by other public health agencies responsible for prophylaxis administration.

Background Cook County, Illinois, is the second most populous jurisdiction in the United States. The CCDPH is one of 6 certified health departments operating in Cook County.9 The CCDPH serves a large and complex jurisdiction in suburban Cook County, covering more than 2.3 million residents, over 700 square miles, 125 municipalities (each operating under home rule), 30 townships, more than 1,000 schools and daycare facilities, and some of the wealthiest and poorest populations in the country.10 To assist with public health emergency planning in such a complex and dynamic jurisdiction, CCDPH has adopted the Federal Emergency Management Agency (FEMA) National Preparedness Cycle to ‘‘ensure a continuous cycle of planning, organizing, training, equipping, exercising, evaluating and taking corrective action in an effort to ensure effective coordination during incident response.’’10,11 The CCDPH has incorporated each component of the planning cycle into agency and municipal preparedness planning. Additionally, to assist with the overall strategic response, CCDPH has identified an incident management team (IMT) to be activated for overall planning and operational decision making during a public health event. At the local level, CCDPH works with POD management teams to effectively plan for activating, operating, staffing, Volume 12, Number 2, 2014

and demobilizing each community-based POD that has been strategically identified throughout suburban Cook County. In addition, the multidisciplinary POD management teams (PMTs) are tasked with identifying who at the local level will lead POD operations via an incident command system (ICS) structure (Figure 1).

Methods

Exercise Development To evaluate existing plans and to create a model for community-based PODs, a full-scale exercise was planned to test both the CCDPH’s current strategic plan for pharmaceutical distribution and the Triple Community (TripCom) local mass dispensing plan. The results of this exercise would provide a framework for improvement and implementation among the other communities of suburban Cook County. POD simulations have been used by public health authorities to assess planning, facilities, volunteers, citizen readiness, and various other criteria.12,13 The full-scale exercise built on the results of a discussion-based tabletop exercise conducted in 2011 and was planned in collaboration with the TripCom POD management team that serves 3 suburban Cook County municipalities and the TripCom Medical Reserve Corps (MRC) and included other health department officials to act as evaluators and controllers during the exercise. The goal was that the lessons learned from this exercise would inform CCDPH on the important and necessary changes that it would need to make to other community-based POD plans in suburban Cook County. The results from the 2011 tabletop exercise helped to identify a number of areas that needed to be evaluated during a live exercise scenario executed by CCDPH and the TripCom POD management team to effectively evaluate TripCom and CCDPH’s planning: (1) communication; (2) joint municipal emergency operations center (EOC) management; (3) mass prophylaxis, including just-in-time training and POD setup; (4) volunteer management; (5) onsite incident management; and (6) public safety and security response. Using FEMA’s Homeland Security and Exercise Evaluation Program (HSEEP) principles, planning for this exercise began approximately 1 year in advance and required a number of exercise planning meetings that included CCDPH, the identified POD locations, the TripCom POD management team, and the TripCom MRC. To successfully conduct the exercise in the most effective way possible required the support of the CCDPH staff, local and regional volunteers (TripCom MRC, Cook County MRC, and other community-based MRCs in suburban Cook County), and the local municipal police and fire departments. In addition, the cooperation from the POD sites was instrumental in facilitating the logistical components for the full-scale exercise. This included 107

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IC/UC

Liaison (optional)

Safety Coordinator

Public Information Liaison (optional)

Operation Section

Finance/Admin

Planning Section Logistics Section

Staffing Food Unit

Clinical Branch

Security Branch

Clerical Group

Volunteer Coordinator

Runners

Situation Unit

Facilities Unit

Exterior

Expedited (separate screening dispensing) Interior Mental Health Triage/First Aid

IT Traffic Reception

Screening Registration

Medical Consult Runners/Hall Monitors

Dispensing Translators

Figure 1. Incident Command Structure for Points-of-Dispensing Operations. This diagram depicts the unified command structure used by the CCDPH during this exercise. The chiefs of the operations, planning, logistics, and finance/admin. sections, in addition to the safety coordinator and public information officer, were housed in the incident command post, while everyone below the operations chief was present in the POD.

The CCDPH, the TripCom POD management team, and the TripCom MRC identified individuals to serve in various exercise roles including players, observers, controllers, evaluators, and actors. The players included TripCom

municipal and facility staff and volunteers from the TripCom MRC, Cook County MRC, other local MRCs, and CCDPH staff. The players staffed all clinical, clerical, incident management, and security positions in the POD (Table 1). The controllers were staff from other local health departments who were responsible for managing exercise play, providing key data to players, and initiating specific player actions to ensure agencies provided feedback on the capabilities being measured. The CCDPH and the

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clearing designated locations in the POD and assisting with POD set up.

Exercise Design

KILIANSKI ET AL. Table 1. Exercise Volunteer Roles MRC Volunteer Role Triage

Reception/registration

Mental health

Translator

Runner

Screening

Medical consult

Dispensing

Pharmacy

Pharmacy inventory management

Table 2. Exercise Schedule Description

Assesses incoming patients, determines whether patients are symptomatic Welcomes patients to the POD, explains the POD setup, handles patient registration and health screening and consent forms Available for any patients who need mental health consult; a licensed psychologist Assists patients who need assistance with language barriers Multipurpose assignment, runners are assigned to a station and perform clerical duties to assist that station Evaluates the brief medical history of each patient and determines what drug should be administered Reviews the complicated patients’ history and decides which drug would be the most appropriate Reviews the information provided by the screener and dispenses medication, hands out information sheets, and provides guidance to patients on taking prophylaxis A licensed pharmacist who ensures that the medication is being distributed correctly; handles the medication Responsible for maintaining the inventory of the pharmacy, restocking as necessary, and distributing the prophylaxis stocks to the dispensers

TripCom POD management team recruited additional volunteers and community members to serve as actors to simulate the role of community residents coming to the POD for prophylaxis. The exercise was designed to take place over the course of 2 days. Day 1 of the exercise took place at the joint municipal EOC, which served as the command center for all local responders in response to a bioterrorism attack (Table 2). The exercise scenario began at 0845 on day 1 with the simulation of a weaponized anthrax release at a local festival, thereby activating TripCom’s joint municipal EOC. Day 1 tested joint municipal EOC management, the ability to activate and mobilize staff and volunteers, and the ability to set up a POD. Volume 12, Number 2, 2014

Time

Activity

Day 1 – Thursday 0730 0800 0815 0845 0900 0900 1200 1200

Exercise site setup Check-in Registration/breakfast Participant briefings Report to exercise location Start of exercise (StartEx) End of exercise (EndEx) Hotwash/lunch

Day 2 – Saturday 0630 0715 0730 0800 0930 0945 1100 1245 1245

Exercise site setup Check-in Registration/breakfast Participant briefings Report to exercise locations Start of exercise (StartEx) Player shift change End of exercise (EndEx) Hotwash/lunch

Day 2 of the exercise focused on POD operations, with data collected on prophylaxis administration and clinic throughput. Day 2 also tested communication between CCDPH, the municipal EOC, the POD incident command post (ICP), and POD staff. On arrival at the POD, all personnel received a briefing on the incident. Simultaneously, participants received just-in-time training on the specific exercise role they were being asked to serve (Table 1). After the just-in-time training had been completed, the exercise began at 0945 (Table 2). During the exercise, actors simulated clients coming to the POD for prophylaxis. At certain points during the exercise, the controllers would simulate scenarios (ie, injects) to players or actors to evaluate the effect on POD operations and player response. At the conclusion of the exercise, an exercise debrief, or ‘‘hotwash,’’ was conducted for all players. Throughout the exercise, evaluators assessed specific capabilities, and they also evaluated feedback during the hotwash.

Results: Exercise Execution

Day 1 The first day focused on the activation and operation of the joint municipal EOC. The EOC began by assembling leaders from the TripCom communities, including first responders, the TripCom MRC, and a team of evaluators (Table 2). Because of exercise time constraints, the players were preassembled at the EOC instead of being notified to assemble as they would be in a real public health emergency. With the EOC assembled, leaders from the 3 109

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The exercise play continued on Day 2 at 0800 (Table 2) with an exercise briefing and just-in-time training for all exercise participants (Table 1). Just-in-time training for players was divided into 3 categories: security, clinical, and clerical. Security assignments were staffed by local first responders. The TripCom MRC members, CCDPH staff, and volunteers from other MRCs staffed the clinical and clerical roles (Table 1). Clinic assignments were based on the medical background of the MRC volunteer, with only the volunteers with medical experience (MDs, RNs, pharmacy, etc) staffing the screening, dispensing, and triage functions. Once just-in-time training was completed, players were deployed to their respective work stations. Two locations in the POD were assessed during the exercise: the clinic (Figure 1) and the onsite incident command post. These 2 locations were physically separated in different buildings during the exercise. The incident command post housed the command and general staff and communicated with the joint municipal EOC and the Cook County Public Health Departmental Operations Center (PHDOC). The incident command post was responsible for overseeing communication in the POD site and between the POD and the joint municipal EOC, and they were also responsible for making administrative decisions and maintaining the POD operations. Communication between the incident command post and the clinic was conducted via portable handheld radios, StarCom radios, and clerical staff who were assigned as runners. The clinic was separated into 2 routes: (1) routine dispensing for people requiring limited or no assistance moving through the clinic, and (2) expedited dispensing for people requiring mobility assistance or those exhibiting symptoms (Figure 2). A triage station was established outside the clinic where staff determined whether a client was symptomatic or asymptomatic and directed the client to the appropriate dispensing route. For exercise purposes, the actors were staged outside of the clinic and were given their pre-

completed health screening and consent form, which identified the type of client they would be simulating. The clients then entered the POD through a single entrance, where they were separated into either routine or expedited dispensing. Clients were directed to the reception and registration station after being held in the client staging area. The clients then went through the screening station to identify the type of prophylaxis they should receive according to the CCDPH dispensing algorithm. Additionally, clients also received a drug fact sheet, which provided information about the determined prophylaxis. Linked to the screening station was a medical consult station to which clients were directed if they had any medical issues that required further examination. Once a decision had been made on what prophylaxis to dispense, the clients were directed to the dispensing station to receive simulated ciprofloxacin or doxycycline, along with an agent fact sheet, a drug fact sheet, and information on who to contact if follow-up was needed. The clients then were directed to the POD exit. Clients routed through the expedited dispensing area proceeded through all these stations, which were consolidated and staffed by fewer people, in order to quickly process the individuals through the POD site. Both the clinic flow (ie, throughput) through the POD and the accuracy of prophylaxis administration were quantitatively assessed during the exercise. To test whether the POD was organized so that clients could move as efficiently through the clinic as possible, time stamps were taken for designated clients as they passed through each station (Figure 2). Based on the calculations, clients had an average of 0.58 minute processing time at the reception and registration station. It is important to note, however, that this time is artificially low because clients used precompleted health screening and consent forms for purposes of the exercise. At the screening station, clients took an average of 2.25 minutes to be processed, and those clients who were in need of a medical consultation were evaluated for an average of 6.95 minutes. After it was determined which medication clients should receive, clients experienced an average 1.49 minute wait for prophylaxis distribution at the dispensing station. If clients were identified as needing emergency medical attention or as being symptomatic, they spent an average of 0.87 minute in triage, and clients needing expedited assistance spent an average of 2.37 minutes receiving their medication (Figure 3). Overall, the time spent on dispensing was 105 minutes, and 427 clients were processed through the POD by 6 dispensers, for an average of 40.67 clients processed per dispenser per hour. In addition to clinic flow, the accuracy of prophylaxis distribution was also analyzed (Table 3). A total of 428 doses of medication were distributed: 361 doses of doxycycline, 63 doses of ciprofloxacin, and 4 doses to be determined by medical consult. Of these, 344 doses were to be given in the standard dosage based on the CCDPH

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communities were provided a briefing and an overview of the simulated scenario. The exercise was initiated with an automated notification message alerting the community to a potential anthrax release. Because of a malfunction in the primary automated notification system, CCDPH activated its secondary manual notification: a direct phone call to the local dispatch center, acting as the primary TripCom point of contact. Once notification was completed, the joint municipal EOC began simulating the activation of the point of dispensing at identified POD locations. An incident commander was identified, and a team was sent to the POD site to begin setup and to conduct a security sweep of the facilities. Communication was also tested between the EOC and the POD incident command post.

Day 2

KILIANSKI ET AL.

Figure 2. Clinic Flow Diagram of POD. Clients entered the POD and were screened at triage, then sent to either expedited (left side of building) or routine (right side of building) dispensing. Clients sent to routine dispensing went through reception and a waiting area and then were sent to registration. These clients then proceeded to screening, medical consult if necessary, and to dispensing to receive prophylaxis. Stations underlined were used to determine flow rate through the POD.

dispensing algorithm, with 84 pediatric doses. Medication errors were broken down by the screening, medical consult, and dispensing stations. The screening and medical consult processes were considered primary errors, and errors made by the dispensing station were considered secondary errors. Incorrect dosing was identified as the most common problem, with 37 primary and 3 secondary dosing errors (Table 3). Furthermore, paperwork errors occurred as well, including failure to correctly note what medication should be given, or incomplete forms being filled out when the client’s medication was distributed. Once a patient received his or her medication at the dispensing station, he or she received drug fact sheets; 163 clients reported that they did not receive the drug fact sheets describing how to take the medication. Included in the exercise was the introduction of injects (Table 4). The injects included items such as non-Englishspeaking clients, 2 clients arguing in line, bottlenecks at the dispensing station, and POD staff requesting a break in the Volume 12, Number 2, 2014

middle of a shift. Also included was a simulated shift change. These injects were designed to test contingencies built into the POD plan and simulate realistic clinic flow disruption. A debriefing, or hotwash, was conducted for immediate evaluation of the POD operation.

Discussion Cooperation from CCDPH, the TripCom POD management team, the TripCom MRC, and other community members was instrumental in the success of this exercise. The communities were able to assess the current dispensing plan in place for POD operations, assess training and staffing roles of a local MRC, and gain valuable information on how the plan can be improved in future iterations. Both quantitative and qualitative observations from the evaluators and the exercise participants (both MRC and 111

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Figure 3. Clinic Flow of Clients Through the POD. Time stamps were taken for each patient who passed through these checkpoints, and the mean time spent at each station is represented here. Stations shown here are underlined in the clinic flow diagram (Figure 2) and were staffed by the MRC volunteers filling those specific roles (Table 1).

actor volunteers) were used to develop a comprehensive after-action report and improvement plan (AAR/IP) for use by the CCDPH. The analysis of the exercise is based on a quantitative analysis of the clinic flow rate and the accuracy of prophylaxis distribution in addition to qualitative data from evaluators, observers, and exercise players. The analysis is broken down by the capabilities measured: communication, joint municipal EOC management, mass prophylaxis, volunteer management, onsite incident management, and public safety and security.

Communication Throughout the exercise, communication of incident response information according to agency protocols was followed, and effective communications were established with incoming personnel. Day 1 of the exercise involved activating POD operations from the joint municipal EOC

for the 3 communities, which was centrally located and had access to various communication modalities. Some limitations of the physical characteristics of the chosen EOC location were identified once the exercise began, including poor cellular phone and radio reception in the EOC, which severely limited communications to and from the EOC. Based on the exercise’s after-action report and improvement plan, the TripCom POD management team will work together to assess solutions to each communication issue in the joint municipal EOC. The TripCom POD management team will develop a tactical interoperable communications plan (TICP) as a means of documenting the interoperable communication resources available. Increased communication drills also will be implemented to routinely assess interagency communications, interoperability, and cooperation of these communities and their stakeholders. On day 2, communication was impaired between the clinic station supervisors and the POD incident command post because of a limited numbers of runners and handheld radios. This led to a breakdown of the operational picture because the operations section chief and other command staff were stationed in the incident command post and could not effectively assess the needs of the POD as the operation progressed (Figure 1). A separate location was identified for the incident command post that had better access to computers, printers, and phones, but once exercised, the location proved to be challenging for overseeing the operations of the POD. The following communication improvements should be incorporated into the plan by the POD management team: 1. Identify and staff an operations section liaison to observe and support POD operations by relaying information to the operations section chief and POD incident command post. 2. Further assess the need for additional handheld radios by reviewing the POD positions that require radios. If each station supervisor is equipped with a handheld radio and channels are established for communication in the POD and incident command post, information will flow more efficiently. 3. Train municipal staff and volunteers who do not routinely use radios in proper radio use.

Table 3. Accuracy of Prophylaxis Distribution Correct Drug to Be Prescribed

Correct Dose to Be Prescribed

Doxycycline: 361 Ciprofloxacin: 63

Regular: 344 Suspension: 84

Consult: 4

112

Errors (Primary)

Errors (Secondary)

None: 365 Incorrect dose: 37 Wrong medication: 14 Dose correct, but incorrectly noted: 8 Medication not documented: 2 Missed medical consult: 2

Incorrect form: 14 No documentation of translation services: 8 Not given suspension: 5 Incorrect dose: 3 Incorrectly prescribed cipro: 3 Doxy given despite allergy: 1 Correct dose, wrong medication: 1

Information Sheet Given Yes: 263 No: 163

Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science

KILIANSKI ET AL. Table 4. Exercise Injects to the POD During Operation Inject Mode

Sent To

Description

Controller

Pharmacy inventory control

Paper Paper Paper

Specified actors Specified actors Specified actors

Paper Controller

Specified actors Specified actors

Paper Controller Sign-in sheet

Registration Incident command post Clerical group supervisor

Paper Paper Paper

Runner at staging Screening supervisor Specified actor

Paper Paper

Clinical screener Pharmacy inventory control

Prompt to submit inventory report to clinical branch director if not already completed. Client presents at triage and only speaks Spanish or Russian. Client is agitated while standing in line and verbally hostile toward staff. Two clients get into an argument while waiting in the screening line. One client pushes the other client. Once security arrives, victim demands that the other client be removed from site. Client is a 13-year-old (minor) who is picking up medications for entire family. Controller tells actors to walk around without identification (badge/lanyard) and have security check them. Actors states they are a client who is lost and needs to get meds, who is hungry, or who needs to go to the bathroom. Running low on pens at registration; need additional pens at the station. Warning of upcoming shift change and begin shift change. During shift change there is 1 person unaccounted for at Registration (AKA extra name on sign-in sheet, no staff actually missing). Runner lets multiple people through directly to screening to create bottleneck. There is a bottleneck at screening; need to request additional staff. Actors’ symptom form says they should receive doxy but instead screener indicated they should receive cipro. Clinical screener is feeling lightheaded and requests to take a break. Doxy supply is running low; resupply is necessary.

Joint Municipal EOC Management The members of the joint municipal EOC worked well together toward achieving their common goals. The EOC was staffed by representatives from the 3 communities. These representatives’ primary role was to make joint decisions on how to support POD operations and allocate resources effectively. While representation from all 3 communities is essential to ensure that each community has an equal voice, the individuals staffing the EOC had not previously trained on joint EOC management. This affected the initial activation of the POD and showed the need for additional and more in-depth training for future exercises and/or an actual emergency. The initial steps in POD activation are the most critical aspect of emergency mass prophylaxis.14 Future activities based on the afteraction report and improvement plan will include joint municipal EOC training sessions to effectively support TripCom operations and resource allocation. With CCDPH guidance, the TripCom POD management team is also developing a checklist of initial POD activation procedures that will be included as an appendix in the TripCom local mass dispensing and vaccination plan. This will ensure that anyone responsible for POD activation can refer to these predetermined initial steps in the plan.

Mass Prophylaxis Day 2 of the exercise focused on mass prophylaxis operations at the POD. Participants had positive observations and feedback: clear directional and station signage, effective use of translation services, the location and set-up of the Volume 12, Number 2, 2014

POD, and the use of TripCom MRC, TripCom municipal staff, and other volunteer groups to support sustainable POD operations. The following POD components were further assessed: health screening and consent forms, justin-time training of volunteers, and the physical set-up of the POD. Health Screening and Consent Form To show client consent and to ensure that the CCDPH appropriately tracks medication and adverse reactions to any medication dispensed, the CCDPH’s health screening and consent form was created to identify the specific medication that should be dispensed to the client. The form is 2 pages long, double-sided, and is translated to Spanish. The form requires the following from the client: name, birthdate, age, gender, address, ethnicity, social security number (optional), mother’s last name at birth, allergies, whether pregnant or breastfeeding, taking theophylline, and a signature for consent. The screening unit completed the medication dosage based on the CCDPH dispensing algorithm and required signatures from both the screener and dispenser. Based on information provided in the form, the staff at the screening station determined and specified the medication the client should receive before the client took this form to the dispensing station to receive the medication indicated. As more clients went through screening, it became apparent that the complexity and length of the form, coupled with the amount of paperwork provided, was significantly slowing the screening and dispensing process (Figure 3). Although CCDPH operates under the family dispensing model, which allows individuals to pick up medications for 113

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their family members, each family member was required to have a separate health screening and consent form. This became very time consuming for individuals who were picking up medication for multiple family members, which is an important way to ensure maximal medication distribution to the community.15 The complexity of the forms and amount of paperwork distributed at the screening and dispensing stations created bottlenecks and added pressure to the staff, which may have resulted in forms being completed incorrectly or incorrect medication being dispensed (Table 3). This exercise clearly demonstrated the need for more streamlined client forms for POD operations. CCDPH developed the standardized health screening and consent form to be used at all PODs in its jurisdiction. In order to streamline the process of completing the form, CCDPH will work on the following: (1) making the form available online prior to POD operations, (2) reducing the number of questions, and (3) creating a family dispensing form that includes all family health information. Another recommendation that came from the exercise was to use a color coding system to identify the medication the client should receive in order to improve dispensing accuracy. Just-in-Time Training All exercise players received just-in-time training the morning of the exercise to supplement prior comprehensive training. Training is an extremely important part of POD operations, as the organization of staff and volunteers are key to the response.16-18 Overall, the just-in-time training enhanced players’ readiness by conducting simultaneous, concise training sessions based on POD position.13,19 Although this training was effective, it was noted that it should be supplemented with concise job- and duty-specific background information to better inform staff on their responsibilities. This hands-on training would be especially important for the players at the screening station. It was at this station that the bottlenecks occurred during the exercise, and, while the physical set-up of the POD also contributed to the problems, the flow of these clients through the clinic could be further increased with improved jobspecific training (Figure 3). Future training sessions will include a clinic walk-through at the beginning of each shift to properly orient each volunteer to his or her role and station location in the POD. To better prepare POD staff, a clinical training session will be added to the MRC training curriculum so that the just-in-time training on the day of POD operations will serve as refresher training.

station (Figure 2) inhibited the screening staff’s view of the client line. This prevented the screening staff from correcting the bottleneck of clients waiting in line, thus causing an inefficient flow of clients (Figure 3). Another contributing factor was the lack of a sufficient number of runners to guide the clients. Having an adequate number of staff at this stage is important for ensuring smooth flow through the entire POD. After clients were screened, they were directed to the dispensing station, which was divided into 3 lines: ciprofloxacin, doxycycline, and combination medication dispensing (ie, for clients picking up multiple types of medication). Because doxycycline was the most commonly dispensed prophylaxis, there was a larger backup in this line than in the others. This led to a bottleneck at the dispensing station of the clinic. Although this was initially a problem, the clinical branch director and the dispensing unit supervisor were able to correct the problem by having both medications available at all of the dispensing stations (Figure 2). The location of the medication in the POD was also of concern, because the boxes of medication were placed adjacent to the exit flow of clients who had already received medication. Evaluators noted that this could lead to stealing and movement of medication by clients exiting the POD, possibly compromising POD operations. These and other physical issues may arise with any POD set-up, depending on the POD location. It became clear that a revised flow plan (Figure 2) might prevent some of the bottlenecks. In future operations, the position of the screening station will maintain clear lines of sight to client lines, and dispensing stations will dispense each type of prophylaxis. To prevent overcrowding and bottlenecks in the clinic, future POD set-up will maximize space by using additional outdoor space for triage and a serpentine client line in the clinic. Further, additional security measures will be taken to secure the medications. The majority of medications will be moved to a separate, secured location to avoid any theft or tampering by clients, and additional security personnel will be posted at the dispensing station. The TripCom POD management team will use additional physical barricades (eg, portable cubicle) around the medication on the clinic floor to ensure its security. Runners and security staff will be responsible for moving the prophylaxis from the pharmacy to the dispensing station by using a pathway separate from the client areas.

Volunteer Management

POD Set-up Proper POD set-up is necessary for efficient client movement through the POD clinic and can ensure proper crowd control. Although the overall POD set-up for this exercise was sufficient, physical set-up of the clinic provided some challenges at certain points. The placement of the screening

This exercise demonstrated excellent regional support and collaborative volunteer participation. A majority of the POD operation was staffed by municipal staff and local MRC volunteers. One of the major successes of this exercise was the number of volunteers that participated, including an experienced volunteer coordinator and an organized TripCom MRC. The TripCom MRC has a structure in place to recruit and train volunteers in preparation for

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public health emergencies. Based on the evaluation of the exercise in the after-action report and improvement plan, it was noted that the TripCom plan needed to integrate the use and management of spontaneous volunteers in POD operation. An emergency situation in the communities served by the TripCom MRC would likely bring spontaneous volunteers to the POD, and these services could be valuable in the operation.13,20 Using CCDPH guidance, the TripCom POD management team will further develop their local mass dispensing plan to detail how the POD and TripCom MRC would address the issue of spontaneous volunteers. This plan will include a strategy for issuing background and credential checks, providing training on POD positions, and managing these volunteers.

Onsite Incident Management The overall incident command of the POD was effective and organized. However, many supervisors assigned to oversee each station also supplemented staff, therefore impeding their ability to resolve issues and communicate resource needs up the chain of command (Figure 1). This issue affected the client flow and may have resulted in medication dispensing errors (Figure 3, Table 3). These problems can be addressed by providing supervisors with additional training on POD operations to ensure they understand their leadership role in decision making and problem solving at the station they oversee. Communication difficulties (eg, radio use) also contributed to a breakdown of the operational picture. The operations section chief was stationed in the POD incident command post (which was located in a neighboring building) and could not effectively assess the needs of the POD as the operation progressed. This exercise identified that an operations section liaison was necessary to maintain operational awareness throughout the POD, incident command post, and joint municipal EOC. Overall, communication between the incident command post and the POD can be improved by assessing which POD staff should receive radios prior to an event, increasing the number of radios available in the POD, and identifying an incident command post location closer to the clinic.

Public Safety and Security Response According to the evaluators, the external security personnel maintained situational and operational awareness throughout the exercise. The security teams consistently kept visual contact with each other to keep radio traffic to a minimum. Security personnel were strategically placed around the POD and inside the POD to ensure that the clients, the POD staff, and the medications were secure. Overall, security personnel were knowledgeable about their roles and were able to intervene and prevent any simulated threats in the POD. Although this was the case during an exercise Volume 12, Number 2, 2014

scenario, if this were a real event, it was noted that the number of security staff stationed at the POD was insufficient to control any actual threat brought by the large number of clients expected at the POD. In a POD designed to serve thousands of people over the course of 48 hours, security would have to be enhanced significantly. Based on the after-action report and improvement plan, the TripCom POD management team will increase the security personnel and the use of physical barriers to ensure the safety of the staff, clients, and medications.

Limitations To ensure all capabilities were measured, artificialities were built into the exercise design. To maximize the number of clients that passed through the POD, a pre-filled health screening and consent form was used. The medical history of each client was preidentified and provided ahead of time to the actors in order to give a diverse set of backgrounds and test the ability of the screeners and dispensers to correctly identify and distribute the appropriate prophylaxis. Because of the use of these precompleted forms, the exercise was unable to test the registration process and the effect on flow-through in the POD. Additionally, labeling of medication at the dispensing station was not measured, which also may have affected the clinic flow. The exercise was also limited by the number of individuals available to participate as players and actors. Although this number of participants, along with the injects used (Table 4), was sufficient to measure the throughput rate, recruiting additional participants would make the simulation more realistic.

Summary Conducting this full-scale mass prophylaxis exercise provided CCDPH with valuable information on how it could improve on the plan to streamline POD operations to effectively dispense medications to its residents. Valuable conclusions were drawn from the quantitative and qualitative data on POD and joint municipal EOC operations. Among all of the lessons learned, incorporating the following improvements would have the most impact for CCDPH planning: 

Improve clinic flow by altering the clinic set-up to reduce bottlenecks. Improve the health screening and consent form and paperwork to be less cumbersome for the client. Reduce screening and dispensing errors by implementing a color coding system for dispensing paperwork.  Incorporate regular training sessions to supplement justin-time training to ensure a response staff that can effectively operate the clinic, incident command post, and joint municipal EOC. 115

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Work collaboratively with community partners, volunteers, and municipal staff to increase resources for security, volunteers, and communication equipment (eg, handheld radios).

Implementing these corrective actions will greatly increase CCDPH POD throughput while ensuring the safety of suburban Cook County residents. CCDPH will continue to collaborate with local partners and volunteers such as the TripCom POD management team and TripCom MRC. Lessons learned from the planning, execution, and evaluation of this exercise can provide a reference for other public health entities when developing mass prophylaxis plans and demonstrate the need for full-scale exercises for public health emergency preparedness and response.

Acknowledgments We would like to thank Lt. Stephen Weiler, exercise codirector, and Ron Sherman, TripCom MRC volunteer coordinator, for their valuable contribution to this work. The TripCom POD management team was instrumental in the planning and execution of this exercise, as was Integrated Solutions Consulting, who assisted in the analysis. This full-scale exercise was supported by the CDC Public Health Emergency Preparedness (PHEP) and Cities Readiness Initiative (CRI) cooperative agreement (Cooperative Agreement # TP12-12010CONT13), administered through the Illinois Department of Public Health.

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