8. Example of a Regional Exercise
The unique characteristics of this project were the driving factors for creating and implementing a regional bioevent-based disaster orientation exercise. The members of the RMBT Working Group had collaborated for 8 months discussing regional issues related to bioterrorism surge capacity. Some of the issues were unique to this region, where the population is widely dispersed and the majority of the medical resources are centralized in a few locations.
The collaboration from all levels of government and from various programs also offered unique insight into some of these regional issues. For instance, DoD members were able to share their specialized expertise in mobile disaster medical surge capacity development. These DoD resources may or may not be available for civilian use during a bioterrorist event, based upon other resource obligations the military would be under at the time of the event.
Since medical response will be local during the initial period after an attack, the RMBT Working Group decided to test the mobilization of medical resources across State lines through an orientation exercise during the final phase of the project. This exercise would address some of the concerns by the six States in meeting surge needs in the event of a bioterrorist attack and initially test some of the ideas/solutions developed by the Working Group.
One of the solutions proposed by RMBT to address surge needs was to equip a medical cache or armory that could be mobilized. As discussed in the section on supply options, three levels of supply caches were recommended (hospital augmentation cache, regional alternative care site cache and a comprehensive cache). These caches of medical supplies can be stored in various locations and mobilized to urban or rural areas and across State lines.
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The exercise was an "orientation exercise" (i.e., scoping type exercise) since many of the roles, issues, and caches are still being defined and tested. An outside expert exercise coordinator from the Denver Office of Emergency Management was invited to develop and facilitate the exercise for the Working Group.
The five primary objectives of this exercise were to:
- Determine the appropriate command and control procedures for deploying a mobile medical cache across State lines.
- Using the 3 different levels of supply caches, determine which cache should be deployed and the factors considered.
- Identify the legal limitations to deploying staff and supplies across State lines and potential solutions.
- Determine the level of staffing that will be required and how and from where they will be mobilized.
- Identify the additional supplies and equipment that will be needed, where they will come from, and how they will be mobilized.
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The RMBT Working Group based this exercise on a simple scenario of a biological event occurring in a rural area of this region. Aid was requested from a neighboring State with available caches.
"On August 8, 2003 at 10:15 am, Colorado OEM has received a request from a neighboring State to possibly lend assistance under the EMAC agreement to a small community in their State. The 50-bed Medical Center in the community has become overwhelmed with an outbreak of an unknown diarrhea agent in a large group of motorcycle enthusiasts on their way to Sturgis, South Dakota. Public Health is investigating the possibility of a contaminated water supply. Despite the Medical Center's full status, patients complaining of chills, fever, and diarrhea are still seeking admission to the facility, with many existing patients becoming angry at the long delays and staff shortage. The State's Department of Public Health decides to set up an alternative care site in town to triage and treat suspected cases. The State does not have the resources readily available to quickly supply/staff this alternative medical facility and requests regional assistance. At 11:15 am, Colorado OEM solicits medical assistance from the Denver OEM. Denver OEM has suggested the possible use of one of Colorado's medical caches such as Denver Health's due to proximity of the surge event."
One of the resources used for this exercise was the Colorado Gubernatorial Executive Orders developed by the State of Colorado (Tool 4). These orders address the issue of licensure requirements for physicians, nursing and emergency medical technicians. This exercise also utilized the Emergency Management Assistance Compact (EMAC), an agreement that can be utilized between States to share resources in disaster response. Of the 50 States, only California and Hawaii do not participate. This resource can be used by States in regional disaster response and coordinates with the Federal Response Plan (FRP).
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1. Determine appropriate command and control procedures for deploying a mobile medical cache across State lines
Issue 1: Who will ask and who will give permission to deploy the asset?
The group agreed that in the case of a State-owned asset, the request and permission should be governor to governor through the EMAC or with mutual aid agreements between County Managers within each State for Border States. If it is a locally owned asset, mutual aid agreements should be developed in advance. If it is a privately owned asset, the receiving State's governor and the private entity should undertake negotiations.
Issue 2: Which entity "breaks down" and distributes the deployed cache?
The RMBT Group consensus was that this is a local responsibility. The asset should be sent to a centralized point and then it is up to the receiving State and local government to distribute. Local receiving authorities should decide what they want and need, where the people should go and what they should do.
Issue 3: What is the hierarchical structure for cache utilization?
This should be locally determined, but would likely mirror concepts put forward in Hospital Emergency Incident Command (HEICS).
2. Using the three different levels of supply caches, determine which cache should be deployed and the factors considered
Issue 1: Which factors should be considered in requesting a level of cache?
There are three possible levels of cache developed by the RMBT Working Group. These assets may be owned by State or private entities. The requesting State could request the asset from either type of institution depending on what they need to address their surge requirements. Factors that should be considered include: Communicable or non-communicable event, access to medical supply resources at site, variation in deployment for each of the three caches, and acuity and number of patients.
Issue 2: Who will transport the cache?
The Working Group consensus was to contract with a local trucking company that can dispatch at anytime, or the local law enforcement. Caches should be in pre-positioned locations. Vehicles that pull the cache may be multi-use for efficiency purposes and availability issues.
3. Identify the legal limitations to deploying staff and supplies across State lines and potential solutions
Issue 1: Licensing for health care providers from another State?
- Investigate and potentially utilize National Reserve Corps concept.
- Create enabling legislation re: licensing.
- Develop gubernatorial orders (Tool 4).
- Utilize Disaster Medical Assistance Teams (DMATs); they are federally credentialed.
Issue 2: When can the resources be deployed?
The Working Group debated whether resources should be deployed when the formal contract is signed or when the verbal agreement is made in the interest of time sensitivity. It is very likely that some resources may deploy on their own.
Issue 3. Who will be legally responsible for costs?
EMAC specifies that the recipient State will reimburse the providing entity for cost of supplies and staffing. If a private entity is providing the asset, a memorandum of understanding (MOU) should be signed during the requesting period.
4. Determine the level of staffing that will be required and how and from where they will be mobilized
Issue 1: Does the cache come with staff?
May depend upon source of cache and any agreements made in advance or at time of deployment.
Issue 2: What will staffing needs be?
This is again a function of number of patients and severity of illness.
5. Identify the additional supplies and equipment that will be needed, where it will come from and how it will be mobilized
Current caches are largely shelf-life-insensitive in terms of supplies and oriented towards basic level care in terms of equipment. Any expectations beyond that will require supplementation from additional resources (such as the Strategic National Stockpile) or entertaining concept of transporting patients to distant hospitals for ongoing care (e.g., utilizing the National Disaster Medical System).
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