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COLORADO’S PLANNING GUIDE FOR LOCAL MASS PROPHYLAXIS OR IMMUNIZATION A Point of Dispensing (POD) Standard Operating Guide (SOG) for Planning Version 3.0 December 2006 1 Note: For this manual, we will follow the convention of italicizing in red specific questions to be answered and ideas for the planners will be in red italics. Examples and other explanatory material, while also serving to instruct, will be in black standard type.. I. Introduction The brief introduction (couple of paragraphs) can be used to give a history of your emergency support function in general or of the demographics of your jurisdiction. This can be any kind of information or background that would not fit anywhere else in the plan and that would give the reader a sense of your operation. It can also be used for a mission or objective statement. Example: This document is intended to support local public health agencies in writing a plan for the activation and operationalization of a Point of Dispensing (POD) in their county. The document is an annex to the X Health Department’s emergency operations plan and will continue to be revised on an annual basis. A. Purpose Why are you writing this plan? Who is meant to read it? The purpose is usually one paragraph, but can be more if needed. Example: This operating guide will be used during a public health emergency. It was created to assist local public health personnel in initiating requests for SNS supplies and implementing rapid distribution measures to protect the general public by the following: Reducing mortality and morbidity Preserving healthcare services infrastructure Minimizing social disruption during a natural or intended disaster The critical elements have been identified by the Centers for Disease Control and Prevention (CDC), the State of Colorado, and the Regional Transfer Point Plan as necessary to successfully initiate and operate Points of Dispensing throughout the state of Colorado. B. Scope The Scope section of a plan limits and defines both geographical areas (list the counties to which the plan pertaibns) and the work itself. Example: This Point-of-Dispensing Standard Operating Guide (SOG) applies to situations defined as a natural or intentional emergency/disaster, terrorist attack, or pandemic event requiring mass vaccination or dispensation of pharmaceuticals to the public within X county. This plan provides details about command and control, legal issues, communications, POD operations, logistics, etc. II. Assumptions Assumptions are a list of things that you assumed would be happening or in place during the disaster for which you are writing the plan. These types of items may seem obvious but they provide context for your plan. The assumptions may not be immediately apparent if a disease outbreak is intended or natural. Other disasters, such as tornadoes, floods, and chemical spills may also require that the general population receive SNS resources. 2 By the time the need to activate the Strategic National Stockpile (SNS) has been determined, the health of the public may already have been impacted and a national emergency may exist. Local inventories of needed pharmaceuticals and medical supplies will quickly be depleted. Personnel, volunteers, and strike teams of epidemiologists may need to be activated throughout the state to accommodate operational periods associated with disease outbreaks. Departmental/County/Regional/State Emergency Operation Centers (EOCs) may be activated. Multiple disciplines, such as medical, environmental, agricultural, law enforcement, coroners, and emergency management will need to cooperatively address the disaster. Disasters that require SNS activation will require effective messages to mobilize the press and utilize Emergency Alert/Emergency Broadcasting Systems to notify the public as well as timely press releases, press conferences, and other vital communications. III. Authority, Responsibility and Legal Issues This section describes any authorities or legal issues. It should reference all applicable state and local statutes, laws and executive orders such as the Colorado Revised Statutes, Homeland Security Presidential Directives, county insurance for volunteers, etc Example: This document quotes and summarizes but does not interpret federal, state or local codes, regulations, statutes or laws. Nothing in this document should be construed as providing legal counsel. Mass clinic planners may wish to consult their legal counsel for any such advice. All applicable codes, statutes, regulations, laws and presidential directives are provided in Attachment X. A. National Response Plan (NRP) In Homeland Security Presidential Directive (HSPD)-5, the President directed that the Department of Homeland Security develop a new National Response Plan (NRP). The NRP is based upon the belief that incidents are typically managed at the lowest possible geographic, organizational, and jurisdictional level. 1. ESF 8 The NRP applies a functional approach and groups the capabilities of departments and agencies into Emergency Support Functions (ESFs) to provide the planning, support, resources, program implementation, and emergency services that are most likely to be needed during an incident. ESF 8 refers to Public Health and Medical Services. 2. Target Capabilities List The purpose of HSPD 5: National Preparedness is to “establish policies to strengthen the preparedness of the United States to prevent and respond to threatened or actual domestic terrorist attacks, major 3 disasters, and other emergencies”. This directive involves capabilitiesbased planning. “Strengthen Medical Surge and Mass Prophylaxis Capabilities” has been identified as one of the national priorities and applies to the mass prophylaxis and medical surge capabilities. B. Colorado Revised Statutes Per guidelines in the Colorado Revised Statutes, State and local departments have statutory authority to “investigate and control the causes of epidemic and communicable diseases affecting the public health.” C.R.S. 25-1.5102(1)(a)(State) and 25-1-506(1)(b)(County). See C.R.S. 25-1-650 for similar authority of public health nursing services. Under the Governor’s Expert Emergency Epidemic Response Committee (GEEERC) statute (C.R.S. § 24-32-2104(8)(e), the Governor may issue executive orders directing measures that may include but are not limited to the following: 1. Procuring and taking supplies of medicines and vaccines; 2. Ordering physicians and hospitals to cease admissions; 3. Isolating or quarantining persons or property; 4. Seizing, destroying or decontaminating property or objects; 5. Disposing of corpses and infectious waste in a safe manner; 6. Assessing the safety of food and water supplies; 7. Providing mental health support; 8. Providing information to the public. C. Regional Strategic National Stockpile Plan Under guidance from CDPHE and CDC, each of the Colorado All-Hazards Emergency Management Regions has developed a Regional Strategic National Stockpile Plan. This plan is the over-arching plan for all of the local POD plans within the region. All regional plans are posted on COHAN. D. Local/County Plan Describe the relationship between the POD plan and the local/county plan, such as how they are the same and how they are different. IV. Concept of Operations A. National Incident Management System Structure This plan operates under the National Incident Management System (NIMS). NIMS is designed to aid in the management of resources through the following concepts: 1. Common terminology 2. Integrated communications 3. Modular organization 4. Unified command structure 5. Manageable span of control 6. Consolidated action plans 7. Comprehensive resource management 8. Predesignated incident facilities B. Regional Transfer Point (RTP) 1. Regional assessment of need, MOU, MOA 4 Briefly describe how your jurisdiction will determine the need for supplies, pharmaceuticals, equipment and volunteers. Who is contacted, what protocol is followed? Reference MOUs, MOAs, COpharm, etc Example: Prior to requesting SNS assets through the CDPHE, the X County/Health Department will coordinate assessment of pharmaceuticals through the COpharm HAN program at CDPHE CMC. - X is responsible for requesting this assessment. - Once the COpharm assessment is complete and data is collected, the Health Officer will make the decision to request the pharmaceuticals from the local pharmacy where the needed medicines are currently being housed. (Should the pharmacy not readily relinquish the medicines, the Health Officer will make a request through the CDPHE CMC to the Governor’s Expert Emergency Epidemic Response Committee to enact draft Executive Order 2.0 - Concerning the Procurement and Taking of Certain Medicines and Vaccines Required to Respond to the Current Disaster Emergency.) - X will be responsible for transport of the pharmaceuticals - and X will be responsible for securing them during transport. 2. Lateral re-distribution of supplies Briefly describe your plan for how pharmaceuticals and supplies will be redistributed within your region or to counties in another region. Who is responsible for transport, security, inventory control, chain of custody, etc? Example: Once the SNS has been activated and the RTP has distributed SNS materiel to local PODs, the POD may determine that their supply is more than the demand. To move SNS materiel from one POD to another - the Liaison Officer will be responsible for contacting other POD locations to determine if they are able to utilize the unused position of the supplies. The POD Liaison Officer is also responsible for coordinating this transfer with the departmental EOC. - If the transfer involves SNS assets, the departmental EOC will make sure to notify the designated CDPHE CMC Liaison. - The POD Logistics Officer is responsible for organizing transport of the materials whereas - the Inventory Control Coordinator will be responsible for starting the chain of custody. The X County/Health Department will coordinate transport from one jurisdiction (county or region) to another through the Liaison Officer at the CDPHE EOC. 3. Requesting SNS assets from the RTP Briefly describe the process for requesting the needed pharmaceuticals and supplies from the Strategic National Stockpile through the RTP. If an official protocol is available, reference this as an appendix. 5 C. Point of Dispensing Protocols 1. Clinical protocols a. Intake The process, procedures, stations and personnel involved in getting people into a POD to be assessed. It also includes the completion of any paperwork. The following stations will be involved in this layer: i. Traffic management ii. Initial entry point iii. Greeting iv. Registration-- Appendix X contains a sample Name, Address, Phone form. This form is available electronically on COHAN and is available for rapid reproduction locally. These forms are available for household distribution of prophylaxis. The form asks for the weight of household members because the dose of many of the possible drugs is determined by the person’s weight. v. Triage How will health history forms be distributed to patients? How will forms be checked for legibility, accuracy and completeness? How will forms be used to route patients correctly so they receive the correct medication in the right dose? How will patients be triaged? Please refer to pages 12-6 to 12-8 about segmented PODs vs. non-segmented PODs. Will triage be conducted at a separate location or at the POD site? This could affect the order in which items are discussed in the clinical protocols section. b. Screening The process, procedures, stations and personnel involved in sorting and classifying patients within the POD to optimize resources and maximize survival of patients. The following stations and roles will be involved in this layer. i. Screening ii. First Aid iii. Medical Transport How will patients be transported to the POD or to treatment centers? Refer to the above comment about segmented vs. non-segmented PODs. iv. Mental Health counseling c. Dispensing The process, procedures, stations and personnel involved in preparing and delivering medications to the public. d. Exit The process, procedures, stations and personnel involved in moving the patients out of the POD, as well as providing any necessary follow-up information. 2. Prophylaxing staff and volunteers. 6 Describe how you will prioritize dispensing medicines to first responders, public health workers, medical workers, etc. prior to dispensing to the general public. Examples: The X County/Health Department will follow the Department of Health and Human Services guidelines for prioritizing the use of vaccines and antivirals during a pandemic. See Attachments X and X for the complete list. For non-communicable disease emergencies, X County/Health Department will provide vaccine/medicines to first responders and families in accordance with state and national guidelines provided by CDPHE and the CDC. This priority list can be found in Attachment X. (Make sure this text is kept up to date with the current guidelines.) CDPHE and the GEEERC jointly reserve the right to make an entirely new priority list at the time of the event, if the circumstances seem to warrant that. 3. Standing Orders The Colorado Department of Public Health and Environment and/or the X County Nursing Service/Health Dept may provide standing orders for vaccine/medication administration, as well as standing orders for responding to medical emergencies, which may occur during a vaccination/medication clinic. See Appendix X for examples of standing orders. 4. Dispensing Oral Meds Briefly describe how this will occur, what procedures will be followed, who is in charge, where will this take place, etc. Example: Pediatric dosing and select geriatric dosing will require some liquid medication preparation. The preparation of these medications will take place under the direction of the Medical Branch Director and must be done by pharmacists or pharmacy assistants. The CDCrecommended preparation procedures should be followed as closely as possible. 5. Language/Translation Services Identify the main languages that will require translation services. Reference who will provide translation services. V. Roles and Responsibilities A. Command and Control The information in this section addresses the question “who is in charge.” Describe the structure of your group for a response. You can also put information about NIMS and your organization’s ICS strategy. Reference the appendix that contains the sample ICS structure with primary and back-up contact information. Example: 7 1. NIMS This plan operates under the National Incident Management System (NIMS). The Public Health Director or designee(s) will respond to a natural or human-caused emergency/disaster, terrorist attack, or a pandemic disease event requiring POD activation using the NIMS structure. 2. Incident Command: Reference your ICS chart in an appendix 3. Staff Support In addition to incident command, additional resources should be available for staff support. A system for insuring staff takes regular work breaks will be in place. This break system will also address the provision of workstation coverage during breaks. The support team will consist of non-medical personnel within X County Nursing Service. Additionally, staff support services will include consideration of the following: a. Risk awareness education, including frank discussions of potential risks and measures for protecting healthcare providers b. Staff involvement in the quality assurance program c. Daily clinic updates d. Opportunities for fearful or anxious healthcare providers to work in other useful roles 4. Mental Health At the local level, it is anticipated that there will be a need for mental health professionals and/or counselors to staff clinics to support, counsel, and calm patients who may be anxious or frightened. An arrangement has been made with X to address these issues. They have staff on-call 24/7 and will respond with the number of counselors needed to fit the situations. B. Communications and Notification 1. Tactical Communications What types of communication systems will you use within your POD? What communication systems will you have at your POD? Two way radios? Runners with message forms? Cell phone? How will you communicate with partners? Who is responsible for maintaining the communication systems and resources for the PODS? Who is responsible for checking and charging batteries, and for testing of communication equipment? 2. Internal Notification Procedures How will you notify your staff in your agency? What protocols do you have in place for volunteer notification? Who is authorized to send out HAN messages? You need to have POD lead/back up list and document that info is updated quarterly 3. After Hours Communication Procedures When your office is closed, how will labs, the state, emergency management or others reach you in an emergency? Through your 911 system? Does your agency have a duty officer? Do you share a pager and rotate call? Describe the procedure here. If there is a written protocol, reference it as an appendix. 8 C. Public Information Public health agencies have a responsibility to maintain patient confidentiality just as if it weren’t an emergency. Look in your local jurisdiction to see what agency is responsible for public information. Public messages should be coordinated through a Public Information Officer. If the incident involves other jurisdictions, there may be a Joint Information Center created to coordinate messages to the public and updates to the press. Describe your plan here. Are there subject matter experts identified in your agency? Example: In the event of a public health emergency, X County will coordinate with the CDPHE EOC PIO. Point-of-contact information for public information personnel is found in Attachment X. After an emergency has been declared, state and local Joint Information Centers (JICs) will assume primary responsibility for all media relation’s activities. When this occurs, a representative of the local health department may be called upon to serve as JIC liaison. Responsibilities of the JIC Liaison are provided. 1. Coordination with Emergency Management Public safety messages often are coordinated through the local emergency manager utilizing reverse 911 systems, Emergency Broadcasting Systems, and the Emergency Alert Systems. Messages to the public can be streamlined to alert the public to shelter in place, evacuate, or location of mass clinic operations. Public health messages pertaining to POD locations have been created and provided to the county emergency manager. These messages will be provided to the public via reverse 911 when PODs are activated. The message includes the description and location of POD facilities. 2. Pre-Event/Event Messaging Uniform messages about the X County POD plan will be presented to the public through state, local and possibly national television and radio networks and newspapers. Messages must convey what the potential problem is and the plan developed to deal with it. Messages must be consistent at all levels and should be delivered by state, local and federal authorities, depending on the circumstances, through a combination of new releases, news conferences, expert interviews, informational videos, public service announcements, the web, presentations, reverse 911 and other means. Message distribution would be primarily through the reverse 911 and the news media. The news media would be handled at both state and local levels. a. Pre-event messages will be developed which advise the population on disease prevention and treatment and preparatory steps being taken by federal, state and local public health agencies via a vaccination/medication plan. The messages can also include education about the “shelter in place” concept that families can use to decrease the risk of disease transmission until clinics are operational in the case of an outbreak. Information will be shared on methods to be used to inform the public and plan for vaccination/medication in case of an event. The public must be 9 reassured that the national vaccine/medication supply is adequate, and that a plan for rapid delivery to each state vaccination/medication site is in place. Information about the need and use of community volunteers may be conveyed. b. Event messages will inform the public that the state and regional SNS plans and the local POD plan are being put into operation and the reason for it along with an explanation of the clinic process. The messages should convey urgency, but not panic, about getting the vaccinations/medications to prevent the disease and other vaccination/medication related information. The messages should include a list of the POD sites, hours of operation, the CDPHE number to call for more information, the timing of the vaccine to prevent disease, adequacy of the vaccine/medication supply, adequacy of the plan and the community resources devoted to carry out the plan. Email messages, signs, posters and flyers about the clinics may be distributed to government offices, school districts, major employers, health departments and medical centers. Notice should be given about public event cancellations if necessary or about arrangements for transporting people to and from the clinic sites. During the POD process, frequent updates should be given about numbers of people vaccinated, the status of active cases of disease and continued reassurance to the community about responding to the outbreak. c. Post-event messages will inform the public that the POD process has ended, the number of people who developed the disease, where to go or who to call in the event of adverse reactions to the vaccinations/medications, the number of volunteers and staff who worked at the clinics and how public health officials will monitor further activity. D. Security 1. Transportation of Materiel Describe the movement of assets from the RTP to the POD including the # of drivers, # and type of trucks, time needed to distribute. Is there availability of sufficient material handling equipment for loading and offloading? Identify distribution staff. Document that they have been trained in SNS specific distribution functions including chain of custody. 2. Documentation of Materiel What chain of custody form is being used? What is the protocol for the use of these forms? 3. Credentialing What process do you have in place to screen volunteers? Do you have a database of volunteers? Have they been trained and possess proper ID? Are you anticipating using volunteers from the Nurse Alert System or local Medical Reserve Corps? Does your insurance coverage require that volunteers be credentialed? How are they covered for exercising, training and response? Example: 10 The volunteers have been pre-screened and have completed a Public Health Civil Defense Volunteer Registration Form. This provides some protection to the county if the volunteer is injured during exercises or actual events. Being a registered civil defense volunteer puts an injured person in a position to file a claim with the State Workers Compensation program (Pinnacol Assurance), if needed. 4. POD Security Refer to the Security checklist in Appendix X. This information is/was used to develop the POD security plan with law enforcement. a. Protection of staff How many personnel will be used to protect workers? b. Crowd Control Do descriptive details for crowd control addressing the questions who will do it, where it will be done, how many people will be involved in doing it, what will be done (signs, information, etc), when will it be done? (in anticipation of the crowd arriving? After the crowd arrives?) c. Traffic control Who will provide traffic control? Consider close parking for those with limited mobility. d. Site Security More than likely, the facilities you use for POD operations are offsite from your public health agency. Managing operations to assure safety and reduce opportunities for injury, theft, and illness are your responsibility. Describe who is responsible for what. Example: The parking and perimeter area will be secured through the local sheriff’s office. E. Safety 1. Facility Safety A Safety Officer should be appointed by the Incident Commander with the following responsibilities: a. Exercise emergency authority to stop and prevent unsafe acts. b. Keep all staff alert to the need to identify and report all hazards and unsafe conditions and insure that all accidents involving personnel are investigated and actions and observations documented. c. Arrange with Logistics to secure areas all areas as needed to limit unauthorized access d. Advise the Incident Commander and Section Chiefs immediately of any unsafe, hazardous situation (review Hazardous Materials Plan). e. Develop safety guidelines for each operational period. 2. Sanitation/Housekeeping Plans will be made for trash and medical waste on-site receptacles, and regular, frequent trash and medical waste removal. Each vaccination/ medication station will have ready access to an adequate supply of sharps containers and biohazard trash containers. In 11 addition, an approved disinfectant will be readily available to use if equipment or surfaces are contaminated with blood or body fluids. Arrangements will also be made for routine and frequent cleaning and maintenance of the POD site. This should include attention to entries and sidewalks (clearing snow, etc), keeping floors clean and free of water or ice, dirt, or litter. Bathrooms, food preparation areas, and staff break or rest areas will be maintained regularly throughout the duration of the clinic. In particular, the actual clinic area(s) will be kept clean and orderly, with regular trash and medical waste removal. 3. Food Service Consumer protection guidelines should be followed to insure proper handling and storing of food. 4. Individual Safety Dependent upon the nature of the incident, the safety of the individual may be protected using various methods. Under the direction of CDPHE and the local epidemiologist, the POD will implement the incident-specific safety measures. Universal Precautions should be used throughout the POD. These precautions prevent direct contact with all body fluids (including blood), secretions, excretions, non-intact skin including rashes, and mucous membranes. Universal Precautions routinely practiced by healthcare workers may include the following: a. Gloves and hand-washing. Clean, non-sterile gloves must be worn when touching blood, body fluid, secretions, excretions, mucous membranes and non-intact skin. Gove are put on just before patient contact is made. Hands are washed immediately after removal of gloves to minimize transfer of micro-organisms to other subsequent patients b. Masks. N-95 disposable half-face respirators may be available in the clinic for use by staff and the affected patient if there is a potential risk for exposure. Increased efficacy will be achieved if staff members are fit-tested with the appropriate mask during pre-event training. c. Eye protection and disposable gowns. These items should be available in the POD in anticipation of an unforeseen emergency, which might require additional protection for the healthcare worker(s). F. POD Facility Set Up Example: 1. Facilities (Site Specification) The POD site will be: ACME Pill Company, 1234 Main St, Here, CO 81234. This site was selected using the CDC recommended Site Selection Checklist. Please refer to Appendix 123 2. Floor plans/Clinic Flow 12 The floor plan has been developed to maintain the safety of workers and patients. Please refer to Appendix 124 for the POD floor plan and Appendix 125 for a clinic flow diagram. 3. Estimated Throughput and Staffing Requirements A model staffing pattern is included in Appendix C, with job action sheets in Appendix B. The staffing model shown is designed to vaccinate/medicate 30 patients/hour, or 2 minutes/patient at each vaccination station. This staffing model will allow X Nursing Service/Health Dept to vaccinate/medicate all individuals in X County’s permanent population of approximately X in 2 days. The staff level at X Nursing Service is not sufficient to meet appropriate clinic staff levels. X will solicit assistance from (fill in other organizations). Some suggestions are Emergency Medical Technicians, hospitals, clinics, Medical Reserve Corps (MRCs), Citizen Corps Councils, Community Emergency Response Teams (CERTs), and other service organizations. Other personnel may be available through Mutual Aid Agreements. CDPHE maintains a Public Health and Medical Volunteer System that includes MRCs and other groups and individuals who are willing to volunteer during an emergency. 4. Staff Support An area removed from clinic activities will be provided to enable staff to relax, rest, eat, and drink during breaks at the time they are working in the POD. It will have adequate accommodations, food, and water/beverages. It will be private so that conversations can be conducted without being overheard by clinic patients. It will have adequate lighting and be accessible from the clinic area. G. Controlling Inventory, ordering and re-ordering assets Describe the process. What authorities must be obtained prior to ordering from SNS? Is this coordinated through the County Emergency Manager? How is information transmitted to the Regional RTP Site? Include a communication flow chart that graphically depicts flow of asset request from POD to RTP. What arrangements have been made for assets not included in SNS that are necessary for POD operations (e.g., non-medical support supplies such as paper towels, office supplies) H. Treatment Centers Include a table identifying locations of treatment centers (outpatients), and another table listing the hospitals (inpatients). Reference MOUs in place for those treatment centers. Refer to protocols described in earlier section (POD Protocols,Triage and Medical Transport) VI. Plan Development and Maintenance There is a sheet in the front of this plan to document the date the plan was updated and what changes were made. There is also a sheet to identify what individuals or agencies have received copies (specific version) of the plan. People change jobs and training on 13 these plans is important. How current is your plan, and who has a copy of it? You should review your plan annually and develop a procedure for making updates. VII. Training and Exercises A. Training Describe who will be trained on this plan, training schedules. Be sure to include partner agencies, staff, volunteers, and elected officials. Who is responsible for training? You need to document training of POD leads, back-ups and core workers. Develop a Just-in-time POD worker-training plan. B. Exercises Do you have a three-year exercise schedule? Has the plan been exercised lately? Who is responsible for exercising the plan? In a progressive exercise schedule, various types of exercises will meet the needs of your community to address improved preparation. Table tops, narrowly focused drills, or full scale exercises vary in capabilities, stress levels, time commitments and funding requirements. VIII. Glossary of Acronyms 14