Download Notification and Response - Lorain County General Health District

Northeast Ohio Biological
Incident Plan
VERSION 1.3
APPROVED
8/1/2003
Northeast Ohio Region Biological Incident Response Plan – Version 1.3 – 8/5/2003 1:49 PM
Table of Contents
Table of Contents............................................................................................2
Introduction....................................................................................................5
Types of Situations .........................................................................................5
Hoaxes, Perceived and Actual Individual Threats ...........................................5
Threatened or Recognized Wide-Area Release ...............................................5
Covert or Naturally Occurring Wide-Area Release...........................................6
Early Recognition ............................................................................................6
Notifiable Disease Reporting System .............................................................6
Health Alert System .....................................................................................6
Command and Control.....................................................................................7
Local Communities/County Emergency Operations Plans ................................7
Northeast Ohio Regional Plan .......................................................................7
Northeast Ohio (NEO) Regional Steering Committee ......................................8
Levels of Response and Management ........................................................8
Responsibility for Declarations ...................................................................9
State and Federal Plans.............................................................................. 10
Incident/Unified Command System (ICS) .................................................... 10
Incident Command Post ............................................................................. 10
Emergency Operation Center (EOC) ............................................................ 10
Local and County EOC ............................................................................ 10
Regional EOC ......................................................................................... 11
Regional Advisory Response Team .............................................................. 12
Centralized Communication Control ................................................................ 12
County Emergency Communication Centers ................................................. 12
Mobile Communication/Command Vehicles .................................................. 12
On-Scene Communications ......................................................................... 12
Health Department and Hospital Communication ......................................... 13
Notification ................................................................................................ 13
Command Level Notification .................................................................... 13
Hospital Notification ............................................................................... 13
Public Affairs................................................................................................. 14
Citizen Notification ..................................................................................... 14
Joint Information Center ............................................................................ 14
Meetings with Key Public Officials ............................................................... 15
Public Inquiry Phone Banks ........................................................................ 15
Credentialing ................................................................................................ 15
Responding Personnel ................................................................................ 15
Augmentation of Response and Medical Personnel .......................................... 16
Mutual Aid Agreements and Employee Callbacks .......................................... 16
Spontaneous Volunteers............................................................................. 16
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Augmentation of Medical Supplies .................................................................. 17
Control of Transport Assets ........................................................................... 17
Crowd Control and Site Security ..................................................................... 18
Tracking of Patient Information and Record Keeping ....................................... 18
Diagnostic Testing......................................................................................... 18
Epidemiological and Criminal Investigation ..................................................... 19
Epidemiological Investigation ..................................................................... 19
Criminal Investigation ................................................................................ 19
Regional Medical Advisory Committee ............................................................ 19
Mental Health Services and Rehabilitation ....................................................... 20
General ..................................................................................................... 20
Background ............................................................................................... 20
Roles and Responsibilities .......................................................................... 20
ARC Models ............................................................................................... 21
DMHS Defusing ...................................................................................... 21
DMHS Debriefing .................................................................................... 21
Crisis Reduction Counseling .................................................................... 21
Crisis Intervention .................................................................................. 21
Additional Services ................................................................................. 22
ARC Assimilation Process for Spontaneous Mental Health Volunteers ......... 22
Additional ARC Services .......................................................................... 22
CISM Teams .............................................................................................. 22
CISM Individual Response to Crisis 1:1 Peer Support ................................ 22
CISM Briefing ......................................................................................... 22
CISM Defusing ....................................................................................... 23
CISM Demobilization ............................................................................... 23
CISM Debriefing ..................................................................................... 23
CISM Family Interventions ...................................................................... 23
CISM Kid Interventions ........................................................................... 23
CISM Line of Duty Death Debriefings ....................................................... 23
CISM Follow-up/Referral ......................................................................... 23
The Behavioral Health Authorities ............................................................... 23
Implementation ......................................................................................... 24
Provider Rehabilitation ............................................................................... 24
Prophylaxis ................................................................................................... 24
Determining the Need ................................................................................ 24
Procedures for Focused Distribution of Antibiotics ........................................ 25
Procedures for Mass Prophylaxis ................................................................. 25
Strategic National Stockpile ........................................................................ 25
Primary Location for Receiving SNS ......................................................... 26
Regional Back-Up Plan ............................................................................ 26
Distribution of Material from Airport ........................................................ 27
Mass Dispensing Sites ................................................................................ 27
Order of Dispensing................................................................................ 27
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Patient Information Sheets ..................................................................... 28
Outreach Teams ..................................................................................... 28
Mass Evaluation ............................................................................................ 28
Hospital Diversion ...................................................................................... 28
Patient Evaluation and Triage Centers ......................................................... 28
Tracking of Patients Evaluated and Triaged ................................................. 29
Mass Hospital Patient Care ............................................................................ 29
Expansion of Acute Care Capacity ............................................................... 29
Nontraditional Treatment Centers ............................................................... 29
Hospital Daily Reporting ............................................................................. 30
Sharing of Staff and Supplies...................................................................... 30
Forward Movement of Patients - National Disaster Medical System (NDMS) ... 31
Quarantining................................................................................................. 31
Mass Fatality Management ............................................................................ 31
Jurisdiction for Fatalities ............................................................................. 32
Environmental Surety .................................................................................... 34
Training, Education and Exercise Plan ............................................................ 35
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Introduction
This plan addresses the Northeast Ohio Region’s preparation for and response to
a terrorist’s use of a biological weapon of mass destruction or a naturally
occurring infectious disease outbreak. It includes the procedures and
responsibilities for managing the health consequences of a major epidemic for
which an individual county requires assistance from other counties within the
region or is large enough to affect two or more counties within the region.
This plan considers incidents with 1) up to 100 victims, 2) incidents with between
100-10,000 victims, and 3) incidents with more than 10,000 victims.
Types of Situations
Experience shows that a biological agent may be disseminated in one or more
different ways. It may be directed at a single source such as a governmental
entity, business, residence, etc. or widely such as to a whole area, city or region.
Further there may be an announcement that a person or group has been
exposed to a biological agent or in other cases it may be a covert release with no
indication it has occurred. The focus of this plan is regional, it addresses those
situations where an individual county requires assistance from other counties
within the region or two or more counties are affected by a biological incident
and as such a regional response is indicated.
Naturally occurring outbreaks may also occur and may require implementation of
this protocol.
Hoaxes, Perceived and Actual Individual Threats
During times of normalcy as well as during heightened states of alert, hoaxes
and threatening letters may occur. Further, any situation that increases media
reporting of perceived or real threats is likely to prompt the public to call for
advice and/or investigation. These situations will be handled using available
local guidelines and appropriate safety and health services. Regional resources
will only be used if events exceed the capacity of individual counties and they
request assistance.
Threatened or Recognized Wide-Area Release
The release of a biological weapon may occur as an overt event that is identified
by the presence of a dissemination source or device or where the perpetrator
announces that a biological attack has occurred.
The recognized release of a biological weapon (or credible threatened release)
will prompt a local, county or regional multi-agency response. Also, the FBI will
direct any criminal investigation that will be required.
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Covert or Naturally Occurring Wide-Area Release
The covert release of a biological weapon will likely be an event that is not
recognized until human or animal illness results.
An epidemic that results from either naturally occurring infections or the
intentional release of a biological agent will result in massive demands on the
EMS and healthcare system in the local community, county or region.
For both a threatened or recognized wide-area release (covert or naturally
occurring), an individual county may require assistance from other counties
within the region. If the incident is large enough to affect two or more counties
within the region the plans for mass patient care, mass prophylaxis, and mass
mortuary care outlined in this plan will be utilized as appropriate.
Early Recognition
Notifiable Disease Reporting System
The Ohio Administrative Code requires the reporting of any unusual disease or
group expression of illness, which may be of public concern whether or not it is
known to be of communicable nature.
Disease events or syndromes are reported according to local and/or county
policy. Data is shared electronically with other health departments through the
Ohio Disease Reporting System (ODRS). These data are monitored regularly to
identify clusters and unusual incidence of disease.
In the event of a major epidemic due to a biological weapon or a naturally
occurring infectious disease, the health departments in the Northeast Ohio
Region will augment their epidemiological capacity with support from other
health departments, and if necessary, state and federal (e.g., CDC) resources.
Health Alert System
The Health Alert Network (HAN) uses e-mail and fax to alert and maintain the
awareness of first responders, hospitals, healthcare clinics, pharmacies, nursing
personnel and physicians in Northeast Ohio. The Academy of Medicine of
Cleveland/Northern Ohio Medical Association (AMC/NOMA) will assist in
distributing information to physician members while The Center for Health Affairs
will assist in distributing information to their member hospitals. Reporting
requirements and up-to-date information regarding the clinical features of
bioterrorist agents, diagnostic testing, treatment and post-exposure prophylaxis,
are shared as appropriate.
In events of a regional scope the public will be educated through media public
service announcements that are coordinated through the Joint Information
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Center. Citizens will be educated about self-assessment of situations and where
to receive necessary assessment, treatment and prophylaxis.
Command and Control
The agencies within the local communities initially affected by a biological
incident will likely be local EMS, fire and law enforcement, hospital emergency
departments, primary care providers, outpatient clinics, and hospital-based
clinicians. This will also be true in the event of a major epidemic of natural or
unknown etiology. Both overt and covert incidents will be managed similarly
through the command and control structure.
The health departments in the Northeast Ohio Region will conduct disease
surveillance and epidemiological investigation to determine the cause of illness.
They will also formulate appropriate disease control and prevention
recommendations, in conjunction with the Ohio Department of Health and CDC,
if necessary.
Plans to provide medical care to large numbers of patients, and to provide mass
prophylaxis to exposed or potentially susceptible individuals, will be implemented
at the direction of the health departments in conjunction with the hospitals in the
Northeast Ohio Region, Ohio Department of Health and CDC, if necessary. The
operational details will vary according to the number and location of ill and
exposed persons, and the characteristics of the disease-causing agent.
This plan increases the capacity of the five counties within the region by adding
to existing county emergency operations plan (EOP) a process for counties to
share resources across their borders. This plan supports the philosophy that local
plans be designed to lead to and integrate with county plans, county plans with
regional plans, regional plans with state plans and state plans with federal plans.
This section outlines the command and control component of this plan.
Local Communities/County Emergency Operations Plans
Each county within the Northeast Ohio Region (Lorain, Cuyahoga, Lake, Geauga,
and Ashtabula Counties) has developed and implemented a countywide
emergency management system with corresponding plans, including a county
Biological Incident Response Plan. To participate in this system local communities
have entered into an agreement with their respective county. Activation of these
plans generally begins at a local level and then if necessary, may be escalated to
a county level.
Northeast Ohio Regional Plan
This plan supplements existing county emergency operations plan (EOP) by
adding a process for sharing resources across county borders when
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necessary. For the sake of brevity only those portions of the Response to a
Biological Incident Plan that need to be addressed on a regional basis are
included in this document.
This document is included as an annex in each county emergency management
plan thereby creating the authority for actions taken on behalf of a regional
response. Memorandums of Understanding between local and county health
departments throughout the region allow for sharing of health department
resources. Likewise, Memorandums of Understanding between the hospitals
throughout the region to allow for sharing of hospital resources are being
developed.
Some communities currently have agreements in place that allow for them to
cross county borders in non-major incidents. Also, some counties have
agreements in place that allow them to work together with other counties in
non-major as well as large-scale events. These agreements will continue to be
used.
Northeast Ohio (NEO) Regional Steering Committee
The Northeast Ohio (NEO) Regional Steering Committee1 will update this plan as
necessary to account for changes in county plans region wide. The NEO Regional
Steering Committee represents the public health, public safety and hospital
sectors from the five Ohio counties of Lorain, Cuyahoga, Lake, Geauga and
Ashtabula. Its mission is to assure collaboration with partners from public health,
public safety, hospital sectors and others to protect against and respond to a
terrorist incident involving but not limited to the use of a biological agent.
Levels of Response and Management
In the context of this plan six emergency incident levels are identified below.
These levels are designed to work in concert with and supplement local,
countywide, regional and statewide response plans, MABAS, IMABAS or IMAC
systems or other such types of agreements.
 Local Community Response (Level 1). The incident community is able to
respond to and manage given incidents without assistance from other
communities.
 Local Community Response Using Mutual Aid to Emergency Incident
(Level 2). The emergency incident exceeds the response and recovery
capability of the incident community. Assistance is obtained from
communities that the incident community has mutual aid agreements.
(The MABAS system is an example of this type of arrangement). This is
generally limited to response between local communities that are within
1
Attachment A: Northeast Ohio Region Steering Committee Bylaws
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
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one county (although some local communities bordering on other counties
have established mutual aid agreements).
Countywide Emergency Incident (Level 3). The emergency incident
exceeds the response and recovery capability of the incident community
and assistance is needed from the county and its local communities in
order to respond to and recover from the incident.
Regionwide Emergency Incident (Level 4). The emergency incident is so
large that it exceeds the capability of the county or it extends into two or
more counties and for which the response and recovery requires the
emergency management capacity of the local communities, the county
and parts or the entire region. This would require local communities to
respond across county boundaries.
State Disaster (Level 5). This is an emergency incident for which the
response and recovery requires an emergency management capacity that
can only be fulfilled through involvement of state government. The State,
through the Ohio Emergency Management Agency has in place plans to
manage large-scale emergencies.
Federal Disaster (Level 6). This is an emergency incident for which the
response and recovery requires an emergency management capacity that
can only be fulfilled through involvement of the federal government. The
federal government, through the Federal Response Plan has in place plans
to manage large-scale emergencies.
Responsibility for Declarations
Incident communities are responsible for declaring Levels 1, 2 and 3. In most
communities the incident commander, Chief Executive Officer, the mayor or city
manager or their designee will initiate Level 3 and request assistance from the
county.
The County Commissioners where the incident is occurring are responsible for
activating Level 4 (this plan). The incident county(s) will, through the County
Emergency Management agency(s), contact the other counties to request
assistance. However, this does not preclude local communities from requesting
assistance from neighboring communities through existing MABAS, IMABAS or
IMAC systems. The intent of this plan is to facilitate response of local
communities through their county EMA, across county boundaries, to those in
need.
The State of Ohio is responsible for declaring Level 5. Procedurally the County
Commissioners of the incident community(s) will request state assistance from
the Ohio Governor. The State of Ohio is also responsible for declaring Level 6.
Procedurally the Governor will request federal assistance from the President of
the United States.
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State and Federal Plans
Through its inclusion in the county emergency operations plans this plan is
designed to interface with the Ohio Emergency Management Agency (OEMA).
The interface with the Ohio Department of Health occurs through local and
county health department plans. This plan will be updated as necessary to
account for changes to the plans of the OEMA and the ODH.
State and federal assets are requested with the declaration of Level 5 and 6. The
county plans are designed to dovetail into existing State of Ohio and federal
response plans.
In the event that a Level 6 declaration is not made, or in advance of a
Level 6 declaration, Federal emergency response assistance can be requested
through the National Response Center (800-424-8802). Federal responses to
hazardous substance releases are defined in the National Contingency Plan (40
CFR 300).
Incident/Unified Command System (ICS)
Incident command will be established as referenced in the individual county
emergency operations plan.
When the incident involves multiple agencies or disciplines Unified Command will
be utilized to manage the incident. This will be based on the agencies or
disciplines on scene, their scope of authority, specific goals and tasks for
managing the incident as well as incident protocols.
Unless they relinquish their authority the local community from where the
incident originates will be in charge.
The incident commander or Unified Command will have the ability to direct the
resources to where they are needed. However, each responding community
agency will maintain authority over their personnel and equipment.
Incident Command Post
An incident command post may be established if the care of victims and exposed
individuals is confined to a small geographic area and control measures will be
focused within that area. Otherwise, the EOC may operate as the command
center.
Emergency Operation Center (EOC)
Local and County EOC
Local communities managing an incident within their respective boundary may
elect to activate their own emergency operation center (EOC). Larger incidents
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requiring a countywide response will likely prompt the activation of the county
EOC under the respective county Emergency Operations Plans.
Regional EOC
This plan anticipates there may be a need, in a large-scale emergency, to
establish a regional emergency operation center (EOC) that will assist in
coordinating the regional response and management of the incident. The
location of the regional EOC will depend on the type, location and extent of the
incident. The county EMAs will provide possible primary and backup sites for the
EOC if requested.
The EOC may include representation from the following agencies/departments
(and any others deemed necessary by Unified Command):
Local Community
1. Elected/appointed officials
2. Public Health
3. Public Safety (fire, law enforcement, EMS)
4. Emergency coordinator
County
1. County EMA
2. County Coroner’s Office
3. County Health Department
4. The Center for Health Affairs
5. American Red Cross
State of Ohio
1. Ohio Emergency Management Agency (OEMA)
2. Ohio National Guard
3. Ohio Environmental Protection Agency
4. Ohio Department of Health
Federal
1. Office of Homeland Security
2. Federal Emergency Management Agency Region V (FEMA)
3. Federal Bureau of Investigation (FBI-Cleveland Office)
4. Environmental Protection Agency Region V (EPA)
5. U.S. Public Health Service Region V –(OEP, CDC)
6. National Disaster Medical System
7. Department of Veteran Affairs
Representation from additional agencies/departments will be added to the EOC
as necessary for incident management.
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Regional Advisory Response Team
A Regional Advisory Response Team, made up of key local and county officials
can also be utilized in major emergency incidents. The NEO Regional Steering
Committee will appoint this team. It will be activated to assist in coordinating a
regional response if requested by one or more counties. Upon determining a
need for their response they are notified as necessary.
Centralized Communication Control
County Emergency Communication Centers
Each of the five county EMAs operates an emergency communication center.
These communication centers are available to assist in coordinating public safety
and hospital communications in a large-scale emergency, multi-casualty incident,
disaster, or terrorist event. The Lake, Ashtabula and Geauga County EMAs have
the capability to communicate directly with each other through a secured
telephone link. Communications will take place to and from the EOCs via
landlines, portable radios and cellular communications. All EMAs have a radio
frequency (155.805) they can communicate through to each other.
Mobile Communication/Command Vehicles
Several local communities as well as counties within the region have
communication/command vehicles. These can be used as on-scene emergency
communication/command centers. The decision to deploy these resources will
be made by the incident commander or unified incident command.
Where appropriate these mobile centers will coordinate on-scene
communications among the various response agencies/units. This will allow the
local and/or county communication centers to concentrate on local
communications. The local and/or county communication centers can deploy
additional resources based on direction from the mobile centers.
On-Scene Communications
Local communities throughout the region conduct their radio communications on
a variety of platforms. Some counties have in place a countywide system such
as an 800 MHz system. Other counties have many different radio systems
operating within their borders. There is currently no communication system that
allows the counties to communicate with one another by radio. Interoperability
studies are being conducted in several counties and the City of Cleveland has
applied for a Regionwide interoperability grant.
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Health Department and Hospital Communication
Currently, communication with the hospitals and health departments can occur
through the county EOCs. This system may be utilized along with existing
phones, pagers, cellular phones and email.
The Ohio Department of Health (ODH) is establishing a MARCS Radio System
with base stations, mobile and portable radios throughout the NE Ohio Region as
a mode of communication among health departments and ODH. This plan
anticipates that interoperability will be created between this system and public
safety and emergency management communication systems.
Notification
Command Level Notification
Once sufficient information has been received to determine that a biological
incident or attack has occurred the Emergency Operations Center (EOC) of the
affected county(s) will be activated. A regional EOC will be established if
deemed necessary.
As appropriate, each local community and county will use their existing SOP to
advise the necessary individuals of the biological incident. Each affected or
assisting county EMA will notify the local emergency coordinators in their county
on an as needed basis. The emergency coordinators are responsible for notifying
their respective local public safety officials and elected officials.
Hospital Notification
Each local community and county has a plan in place to notify all area hospitals
of a biological attack or incident and provide them with available information
including:
 Suspected affected area
 Approximate number of potential patients (estimated)
 Suspected biological agent used
 Any additional information available
Unaffected County EMAs from within the region will assist with the hospital
notification in affected counties that request it.
The local and/or county health departments are responsible for further
communicating with area hospitals through the hospital’s infectious disease and
emergency department practitioners. Unified incident command will assist as
necessary.
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Conversely area hospitals may be the first to draw attention to an increasing
patient population or they may identify the presence of one or more indicators of
a biological event and contact local, county, state or federal health officials.
Public Affairs
Public information and affairs are integral to any major operation. Public panic
and unnecessary movement may be mitigated with the proper use of the media.
An important underlying theme in managing news is to assure its accuracy
before releasing it.
Citizen Notification
In the event of a large-scale emergency, multi-casualty incident or terrorist event
where the public must be alerted each county will activate specific protocols to
notify their citizens. These protocols are set in motion at the request of the
incident community. These protocols address the use of the Emergency Alert
System (EAS).
Local communities throughout the region have procedures in place to alert
citizens through the use of personnel going door-to-door, and conveying
messages through emergency vehicles public announcement (PA) systems. If
necessary, county evacuation protocols will be activated.
Counties from within the region will assist with the emergency notification and/or
evacuation in affected counties that request it. The affected local and/or county
health departments are responsible for making contact with the health
departments that will be requested to help. Unified incident command will assist
as necessary.
Further, press releases, interviews and press conferences will be used to spread
the message to the public through the local news media.
Joint Information Center
If determined necessary, a Joint Information Center will be established to
coordinate communication with the media. This will likely occur at Level 3 and
higher. All press releases should be developed and issued jointly and all news
conferences should be held jointly to ensure that the public does not receive
inconsistent and misleading information. However, this does not preclude
information from being released by designated officials at the scene provided
that the necessary steps are taken to assure that any such information is
coordinated and accurate.
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Meetings with Key Public Officials
Throughout the incident meetings will be held with key public officials to identify
the information to be released and the frequency for doing so. Emphasis will be
placed on accurate and timely releases of information.
Public Inquiry Phone Banks
If deemed necessary, to answer citizens’ questions regarding the existing
emergency phone banks will be activated and staffed. These phone banks will be
staffed twenty-four hours a day, seven days a week (or as deemed necessary).
The Ohio Poison Control Collaborative will provide secondary support by
providing information to the phone banks and maintaining a twenty-four hour
hotline.
Credentialing
For the purpose of this plan, credentialing is broken down into two categories:
responding personnel and volunteers.
Responding personnel are those persons who have a responsibility and are
authorized to report to the incident or sites related to the incident (JIC, EOC,
etc.). This includes local and county first responder, health and hospital
personnel, elected officials, etc. Spontaneous volunteers are those persons who
are not employed by an agency that is involved in responding to or managing
the incident. Also, this category includes employees of a responding agency who
are not authorized as part of their job duties to assist.
Responding Personnel
All sites involved in the incident or management of the incident will be
considered secure areas. Access to these sites will be immediately closed off to
everyone other than responding safety force, health or hospital personnel and
authorized key elected officials. The incident commander will determine entry of
other persons to these sites. Local law enforcement agencies are responsible for
controlling ingress and egress from these sites. Regional, state and federal law
enforcement and/or security assistance will be provided to communities
requesting it. Only those persons who are properly credentialed with dated
identification badges will be given access to these sites. The credentialing
process of responding personnel is not designed to verify current licensure or
certification status, as it is the responsibility of the employer to assure that its
personnel maintain current certification or licensure. Rather the credentialing
process used for this group is designed to make sure they checked-in and are
wearing the appropriate badges.
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Upon determining the need, unified command will identify and assign persons to
a team that will perform the credentialing. Under the City of Cleveland’s
Metropolitan Medical Response System Plan, the Division of Police (CPD) has an
identified team that will be used for this purpose. This team can be requested for
use regionally under this plan.
The credentialing team(s) will be stationed in areas referred to in Credentialing
Center(s). Only on-site areas that have been cleared for safety and security will
be used. If deemed appropriate and available inflatable tents or other such
types of temporary shelters may be used as the Credentialing Center(s).
Signage will be posted at appropriate locations and officers guarding the
perimeter will advise incoming persons of the requirement to report to the
Credentialing Center.
All persons other than uniformed safety force personnel who are responding into
the area will be required to wear appropriate credentials (name badge)
identifying they are authorized access to the area and to the various sites. Nonuniformed officials (other than those identified above) and persons representing
local, county, state or federal agencies entering a site will be required to report
to the Credentialing Center where they may receive appropriate credentials.
Augmentation of Response and Medical Personnel
Mutual Aid Agreements and Employee Callbacks
Augmentation of response personnel should be achieved initially through
utilization of existing mutual aid agreements, MABAS, IMABAS or IMAC systems.
If required additional assets can be brought in through county, regional,
statewide and federal response plans.
Local communities and counties within the region may call off-duty employees
back to work to provide emergency services. This can be done through
established call back systems and the use of the media to broadcast alerts for
safety force, health and hospital personnel to report to work.
Spontaneous Volunteers
The local news media will be used to advise first responders, health care
professionals, and the general public from outlying (unaffected) communities
what agency they should contact in order to volunteer to assist. Spontaneous
volunteers will be discouraged from reporting directly to sites, health
departments, EOCs, area hospitals or other such locations. Instead, they will be
directed to a site designated by the American Red Cross in cooperation with the
Academy of Medicine of Cleveland/Northern Ohio Medical Association (physician
volunteers) and Center for Health Affairs (hospital volunteers) for processing and
credentialing. In this process the volunteer’s certification or licensure status will
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be verified before they are considered available for deployment. Lists of available
volunteers (along with contact phone numbers) will then be provided to unified
command as the need for volunteers is identified. Each hospital in the Northeast
Ohio Region has internal a policy that outlines the process for granting disaster
privileges for healthcare providers. These procedures may become activated in
the event of a catastrophic situation where additional manpower would be
immediately required.
Augmentation of Medical Supplies
Each county maintains emergency management capacity inventories that are
updated on a regular basis. These inventories identify where additional assets
can be obtained if necessary. The county EMA is responsible for coordinating
delivery of countywide assets within each county.
In the event of a community mass casualty situation where resources are being
used at escalating rates such that the supplies are decreasing, a Level 3 through
6 Emergency may be declared. This will allow counties to share these resources
regionally and draw in state and federal (including the Strategic National
Stockpile) resources as needed. Further, Memorandums of Understanding
between the health departments in the region allow for a sharing of medical
supplies and equipment between these entities as necessary.
Each county EMA, if requested, is responsible for coordinating delivery of assets
from their county to other counties within the region. Unified command will
assist as requested.
Control of Transport Assets
There are a variety of systems (existing mutual aid agreements, MABAS,
IMABAS, IMAC systems and/or county EOPs) that allow local communities in the
NEO Region to send ambulances to neighboring communities to assist in
transporting patients to hospitals. These will be employed as necessary. The
requesting community or county is responsible for making the required contacts.
Unified command will assist in making these requests or coordinating the
deployment of these ambulances if requested.
The county EMAs, or where applicable, county emergency communication
systems of the affected counties will assist in coordinating the flow of patients to
various hospitals. They will be contacted via cellular phone and/or radio to direct
each transporting ambulance to the appropriate medical facility. The county
EMAs, or where applicable, county emergency communication systems of the
affected counties will maintain regular contact with affected hospitals to identify
current bed availability.
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Additionally, if available and needed private ambulance companies and critical
care ground units from hospitals with the NEO region will be used to supplement
the region’s transport assets.
Transit system buses within the NEO Region may be used to transfer of nonill/injured persons to locations where they will be triaged, assessed and if
necessary, treated. These buses may also be used to transport support
personnel to various areas as needed.
Crowd Control and Site Security
Local law enforcement is responsible for crowd control, site security, traffic flow
and to maintain civil order.
Local hospitals have in place procedures for assuring crowd control and
maintaining traffic flow at area hospitals. Local law enforcement, through the
declaration of a Level 3 (or higher) emergency will supplement the hospital
security forces when necessary. This will be primarily directed at assuring traffic
flow thus allowing the hospital security forces to concentrate on the interior of
the hospital campuses. There are also plan in place for crowd control at facilities
that will be used for mass prophylaxis and mass care.
Local, county, state and federal police forces will be used to supplement security
needs and maintenance of civil order including: local police departments
throughout the region, county sheriff’s office, Ohio State Highway Patrol, Ohio
National Guard, U.S. Coast Guard, U.S. Army Reserve Units.
Tracking of Patient Information and Record Keeping
Prehospital run reports for patients seen and/or transported will be completed
according to established EMS protocols within each local community.
Local and county public health officials will collect patient-related information
from hospitals and other acute care facilities on a daily basis to track the
epidemic. Each local community and county has a plan in place to provide for
patient tracking and record keeping. These systems are also effective for
identifying patients who have self-ambulated to the hospital. The American Red
Cross, HAM radio operators and unified command will assist with these activities
as requested.
Diagnostic Testing
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If the involved area is widespread (two or more counties) the health
departments of the affected county(s), in conjunction with the Northeast Ohio
Regional Steering Committee, ODH and CDC, will make a policy decision as to
whether or not culture testing is to be recommended for persons who may have
been exposed to a biological agent. Counties from within the region will provide
assistance to affected counties that request it. Unified incident command will be
responsible for coordinating this assistance.
Epidemiological and Criminal Investigation
Epidemiological Investigation
Counties from within the region will assist with the epidemiological investigation
in affected counties that request it. The affected health departments are
responsible for making contact with the health departments that will be
requested to help. Unified incident command will assist as necessary.
Criminal Investigation
If it is believed an illegal or terrorist act has occurred local law enforcement and
the FBI have responsibility for conducting the criminal investigation. Counties
from within the region will assist with the criminal investigation in affected
counties that request it. The affected law enforcement agencies are responsible
for making contact with those agencies that will be requested to help. Unified
incident command will assist as necessary.
Regional Medical Advisory Committee
The NEO Regional Medical Advisory Committee under the auspices of the NEO
Regional Steering Committee will be responsible for assisting with the
development of guidelines for disease recognition and diagnosis, treatment,
post-exposure prophylaxis and other disease control measures. This will occur in
conjunction with current treatment guidelines, input from ODH and CDC staff
and other disease experts, and include recommended dosing information for the
general population, and for special populations such as children, pregnant
women, immunosuppressed individuals and individuals with drug allergies. The
NEO Regional Steering Committee will provide final approval for these guidelines.
In the event that these guidelines should become county protocols they will
require approval of the various county EMA boards and local and county health
commissioners and medical directors.
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Mental Health Services and Rehabilitation
General
The area chapters of the American Red Cross (ARC) and the county Critical
Incident Stress Management (CISM) Teams are the primary agencies providing
mental health resources in times of disasters or emergencies in the five county
region. This section covers the function and primary duties of the ARC, and
CISM, during the pre-crisis, crisis, “acute,” and post-crisis phases in times of
disasters and emergencies.
Background
All Red Cross chapters in the region routinely provide assistance to victims of
single-family home fires as well as other disasters that occur. In times of
disasters, the Lorain, Cuyahoga, Geauga, Lake and Ashtabula County Chapters
can call upon the national ARC to augment its local resources.
CISM has a Critical Incident Stress Management clinical and administrative
strategy to address and mitigate acute psychological stress that is associated
with psychological trauma, and to prevent or mitigate adverse post-traumatic
stress sequelae. CISM has been recognized as the standard of care for public
safety, emergency responders, their families, critical care providers, and other
specialized rescuers. CISM is a multi-component crisis intervention program that
spans pre-incident training through the acute crisis to post crisis procedures to
facilitate closure of the event.
The Ashtabula, Cuyahoga, Lake-Geauga and Lorain County CISM Teams are
prepared to provide a comprehensive multi-component system of crisis
intervention services to all first responders, fire, law enforcement, EMS,
communication 911 operators, specialized rescue personnel, critical care
providers, and their families throughout the event with appropriate and timely
care.
Disaster Mental Health Services (DMHS) of the Red Cross are responsible for
delivery of mental health services provided during a disaster operation. DMHS
arranges for emergency and/or additional assistance in meeting individual or
family mental health needs, augments material and personnel to support
community mental health services, and provides necessary mental health care
for staff assigned to the disaster operation.
Roles and Responsibilities
The listing below describes the primary roles and responsibilities of ARC and
CISM during actual disaster or emergency situations. The same roles and
responsibilities also apply during disaster drills and exercises.
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ARC and CISM will provide needed services through the duration of the
operation.
ARC will provide a government liaison to the EOC to facilitate
communication with field operations and provide information regarding
available resources.
ARC and CISM will maintain an on-call schedule during the course of
operations that will provide back up for problems that arise during offhours.
All entities maintain accurate records and documentation of assistance
that is provided.
If additional personnel are required, they will be supplied through the national
ARC and the CISM state and national network. Additionally, Red Cross chapters
may have a Letter of Understanding with mental health agencies in their
jurisdiction to provide additional resources. These agencies will develop
procedures to address requests for mental health mutual aid outside the
designated area.
ARC Models
DMHS Defusing
Defusing is used for the groups identified above. It is an informal but structured
five - step discussion of feelings and reactions to the event. Defusing is
conducted within 24 hours of the event.
DMHS Debriefing
The DMHS provides a five-step formalized process to ARC volunteers upon
termination of their duties, prior to their return to home. The goals include
placing disaster experience in perspective, developing strategies for coping
difficulties, and to acquire realistic expectations. This model can be modified for
community interventions as needed.
Crisis Reduction Counseling
Crisis Reduction Counseling may range from casual inquiry about how people are
doing, feeling, or coping, to protected and private discussions about a particular
need or issue. It involves active listening, demonstration of empathy, validating
feelings and normal reactions, assisting in the prioritization of current problems,
education of normal responses and sources of support. It is not therapy and
does not deal with intrapsychic issues. It does not deal with long-term or
chronic problems requiring in-depth counseling or Crisis Intervention defined
below. It deals only with issues related to the disaster.
Crisis Intervention
Crisis intervention is counseling conducted with an individual in order to mitigate
extreme emotional stress. The DMHS assesses a person’s ability to cope, and for
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the seriousness of the problem. Services are for (though not limited to) the
affected neighborhoods, “worried well,” volunteers, and their families. This is
accomplished by a Disaster Mental Health Services worker and may occur in
many settings. It is limited to two sessions and two follow-up checks.
Additional Services
Persons needing services beyond the four above mentioned standard Red Cross
DMHS intervention described above, direct referral will be made to community
mental health and alcohol drug treatment centers with the permission of staff
member or client following accepted standards of confidentiality and privacy.
ARC Assimilation Process for Spontaneous Mental Health Volunteers
ARC DMHS officers will provide a modified ARC DMHS course to prepare the
individual to function in assigned operations. All spontaneous mental health
providers must show current licensure and proof of identity prior to DMHS
training. They will also be screened for their suitability for the event.
Additional ARC Services
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Referrals
Service Centers
Kitchens
Warehouses
Walk-in Crisis
Shelters
Integrated Care Teams
Emergency Aid Stations
CISM Teams
CISM Individual Response to Crisis 1:1 Peer Support
Trained CISM peers will provide appropriate “SAFER 5-step Model,” individual
intervention as needed for individuals not currently involved in an operational
function. This intervention can occur anywhere, including areas designated for
responder rehabilitation, break rooms, and designated quiet areas.
CISM Briefing
This is a brief, four-step group intervention process designed for 10-300
individuals who have experienced a common event. The briefing will present
relevant facts, address rumors, and reduce anxiety. An intervention can occur
anywhere including areas designated for responder rehab, break rooms, or
designated quite areas.
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CISM Defusing
The defusing is a brief; three step group process for those individuals involved in
the incident who have experienced an extreme risk to self or peers. It should be
provided within hours of the event.
CISM Demobilization
For catastrophic events involving at least 100 providers, this is a one-time, unitspecific, group process. It is intended for personnel being dismissed from the
event, who are returning to their point of origin, and who are not expected to
return to this event. The brief group process consists of 10 minutes of
information regarding the event, stress management, and referral services
available, followed by 20 minutes for food and rest prior to event dismissal.
CISM Debriefing
This is a formalized 7-step group process for individuals of similar backgrounds
involved in a critical incident. This should occur days to weeks following the
completion of a catastrophic event,
CISM Family Interventions
A formalized 7-step group process for spouses and significant others of
individuals involved in a critical incident.
CISM Kid Interventions
This is a formalized 5-step process for children. Trained professionals provide it.
It can be accomplished several days to weeks following the catastrophic incident.
CISM Line of Duty Death Debriefings
These include a two-day debriefing process. On day one, there is a formalized
5-step process, followed several days after the funeral with a formalized 7-step
process.
CISM Follow-up/Referral
All crisis intervention will have follow-up with personnel, and the ability to
provide referrals to specialized care following any major incident. This may
include utilization of the national CISM on-site academy utilized for professionals
experiencing post-traumatic stress reactions following an emergency or disaster.
The Behavioral Health Authorities
The Behavioral Health Authorities from the region are responsible for all public
mental health and alcohol drug treatment services in the five counties. The NEO
Steering Committee will enter into discussion with the Behavioral Health
Authorities to develop a plan for all contract agencies to create a Comprehensive
Disaster Mental Health Plan (Plan) for the five counties. The Behavioral Health
Authorities in the region are: The Lorain County ADAS Board, Cuyahoga County
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ADAS Board, Cuyahoga County CMH Board, Lake County ADAMH Board,
Ashtabula County Mental Health and Recovery Service and Geauga Community
Board of MH and ADA Services. The Plan will define:
 A system of referral. The Behavioral Health Authorities in Ashtabula
Cuyahoga, Geauga, Lake and Lorain will be requested to work with its’
contract agencies to develop a system for the referral for persons
identified by ARC or CISM in need of services that are beyond the scope
provided by CISM or ARC.
 Training of agency staff in the special body of knowledge pertaining to
disaster mental health.
 A policy for employees providing volunteer service outside the agency in
time of disaster.
The behavioral health authorities will ensure that the plan is consistent with
requirements of the Ohio Department of Mental Health and the EOPs of the five
counties.
Implementation
ARC, behavioral health authorities, and CISM will work collaboratively with other
functions; e.g., health services and social services, to provide comprehensive
care for victims. Incident Commanders or the EOC can request implementation/
activation through ARC on-call personnel.
Provider Rehabilitation
Once the needs of the incident have been established and safety of the sites
assured the American Red Cross and Salvation Army will take steps to set up and
provide “rehabilitation” to safety and EOC personnel.
Prophylaxis
In order to respond to a major public health emergency, a mass prophylaxis plan
has been developed by the NEO Steering Committee to provide rapid distribution
of antibiotics or vaccines to all residents of the region.
Determining the Need
Events involving 1-100 casualties may be handled with existing local and county
resources (if the agent is not transmissible from person-to-person). However,
events involving 100-10,000, and >10,000 casualties or exposed individuals will
likely require additional resources such as a regional response and deployment of
the Strategic National Stockpile (SNS), especially if the potential for person-toperson transmission is high.
Individuals will receive vaccine/medication based on either exposure history or
other determination of disease risk, depending on the biological agent causing
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disease. Recipients may include individuals with a specific exposure history
(e.g., residents in a specific location, attendance at a specific event), specific
occupations (e.g., first responders, health care workers), risk factors for illness
(e.g., elderly, immunocompromised), or may include the entire population of the
region. In most cases, these decisions will be disease specific. Priority will be
given to prophylax those at highest risk of disease.
Procedures for Focused Distribution of Antibiotics
Local caches are maintained with a supply of antibiotics to meet the initial
demand of a suspected biological event. Those persons considered on the front
line for treating patients (e.g., EMS, fire, police), healthcare workers, mass care
clinic staff, or other individuals (based on either symptoms or exposure) will be
prioritized to receive appropriate antibiotics or vaccine. Unified Command, with
input from the NEO Regional Steering Committee, will make the decision to
release and distribute existing supplies to individuals identified by the appropriate
governmental authority.
The location, mechanism of distribution, and staffing is described in detail in
each county’s Mass Prophylaxis Plan.
Initial pharmaceutical supplies for hospital-based health care workers will come
from supplies on hand at hospitals, and then from pharmaceutical distributors
having existing contractual relationships with hospitals. In certain scenarios,
local pharmaceutical caches may be diverted to hospitals for prophylaxis of
hospital-based health care workers. Depending on the prophylaxis needed and
based on CDC/ODH recommendations the hospitals may use their own staff and
supplies to provide vaccination and medication internally.
Procedures for Mass Prophylaxis
Once the focused distribution population has received its supply of antibiotics,
the general population in likely affected areas will begin receiving an initial
distribution of antibiotics at specified mass dispensing sites. This effort may be
combined with distribution of antibiotics through local hospitals and pharmacies.
Counties from within the region will assist with the distribution in affected
counties that request it. The affected local and/or county health departments are
responsible for making contact with the health departments that will be
requested to help. Unified incident command will assist as necessary.
Strategic National Stockpile
If resource needs are determined to exceed local and regional supplies, a Level 5
emergency will be declared and the County Commissioners of the affected or
assisting counties will contact the Ohio Governor’s Office, to request deployment
of the Strategic National Stockpile (SNS).
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Primary Location for Receiving SNS
The primary location to receive the SNS in Ohio is Rickenbacker Air Force Base.
A secondary location is the Franklin County Fair Grounds. The ODH will
coordinate the breakdown of the SNS and shipping to the pre-identified
dispensing sites within the NEO Region.
Regional Back-Up Plan
If necessary, Cleveland Hopkins International Airport (or another identified site)
may be utilized as an alternative local receiving site. Individuals from the Centers
for Disease Control (CDC), the Ohio Department of Health (ODH), and the City of
Cleveland and Cuyahoga County will meet and receive the shipment.
Cleveland Hopkins International Airport is a city-owned airport and a protocol is
in place to land the airplane, receive and unload the SNS cargo containers, break
it down and store it until it is distributed. Airport personnel and off-loading
equipment will be available to assist with unloading the SNS.
The material will be unloaded into one of three (1st choice, 2nd choice, 3rd choice)
airport hangars. Once unloaded the shipment will be broken down and stored in
one of the three first choice airport hangars, the Airport Rescue Fire (ARF)
station, or the Cleveland International Exposition (I-X) Center. The airport
hangars and the Airport Rescue Fire station are located within the airport
property while the I-X Center is located adjacent to the airport and can be easily
accessed from the airport. All identified locations are appropriately climatecontrolled.
At this point, equipment (e.g., ventilators, PPE, intravenous catheters, etc.) will
be sorted from medications and vaccines. Staff from the city’s public health,
safety, port control and utilities departments, the county’s board of health and
emergency services and area volunteers will perform the separation of the SNS
including the breakdown of medication into individual-dose units (if required).
Local pharmacists will be onsite to direct this activity. Local health departments
are currently identifying these pharmacists. The City of Cleveland and other
regional partners as necessary will provide logistical support on site.
Alternatively the plan is flexible enough to allow items to be transported to
another central breakdown point (e.g., Cleveland Convention Center) where bulk
medication/vaccine are broken down into either individual doses or into
quantities that can be easily sorted at mass dispensing sites.
If a regional distribution is planned, state assets as well as city, county and
regional assets may be deployed to receive and unload material.
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Distribution of Material from Airport
Specific materials will then be transported directly to mass dispensing sites,
hospitals and/or other sites, depending on the size of the operation and the
number, location and the needs of those sites. Unified command will make this
decision. The mass dispensing sites will be used to provide mass prophylaxis to
large numbers of people (e.g., approximately twenty thousand per site). Local
and county law enforcement and potentially the Ohio National Guard will provide
security of these sites. If possible, equipment such as ventilators, PPE and other
patient care equipment will be transported directly to hospitals and other sites
that need it. The Ohio Department of Health will be responsible for controlling
and tracking the distribution of medications and equipment.
If necessary, the city will provide vehicles from the departments of safety,
utilities and parks and recreation to transport the equipment, medical supplies
and pharmaceuticals to the various locations. Additional vehicles from other
local, county, state and federal sources will be requested if necessary. City
personnel will drive vehicles, with additional support from other local, state and
federal resources, as needed.
The Cleveland Division of Police (CPD) will provide security for the breakdown
and storage portion of this operation. Local law enforcement, Ohio National
Guard and Department of Defense assets may support them as necessary.
Mass Dispensing Sites
Each county has identified sites to dispense antibiotics and/or vaccines to the
general public. These same sites will also support patient evaluation and triage
needs.
Order of Dispensing
The persons considered “most at risk” would receive antibiotics first. This
selection will be based on findings of the epidemiological investigation. Unified
command will then make a policy decision as to who will receive additional
supplies for prophylaxis.
In order to receive prophylaxis persons will undergo a screening process to
identify if they qualify (are part of the affected population) for the medications
and also to assure they are not allergic to the available medications. A log with
each person’s name that receives prophylaxis will be kept on file by the health
departments responsible for providing the prophylaxis.
A local official will be in charge of each site. A health department official will be
responsible for controlling and tracking the distribution of medications and
vaccines at each site.
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Patient Information Sheets
Patient Information sheets regarding the medication and/or vaccine to be
distributed will be developed and made available to recipients. They will also be
made available in languages other than English, as appropriate. These sheets
will be based upon existing information sheets already developed by the Ohio
Department of Health, and CDC. These sheets will include possible side effects
as well as information for special populations who may require alternate dosing
or medication. If necessary, alternative forms of therapy will be available for
individuals who fall into these categories.
Outreach Teams
Specific “outreach” teams will be utilized (comprised of local, state, federal
resources, as necessary) to provide medical information and supplies to
homebound populations, the elderly, etc. These teams will work with local
volunteer and city and county agencies that work with specific populations that
would have difficulty accessing triage or mass dispensing sites.
Mass Evaluation
Northeast Ohio area hospitals have incorporated planning for a biological weapon
of mass destruction event into their existing disaster plans. These plans include
provisions for decontamination (if needed), evaluation and triage of large
numbers of patients; estimation of security needs, as well as plans for mass
expansion of acute care beds for patients. The disaster plans also address
scenarios including a range of infection control requirements (e.g., standard
precautions, respiratory precautions, contact precautions) and acute care needs
(e.g., ventilator-dependent patients, intravenous medication, etc.). The Center
for Health Affairs and other hospital groups will assist hospital systems and
individual hospitals with the development of such plans.
Hospital Diversion
Large events that result in hundreds or thousands of asymptomatic individuals
presenting for medical evaluation will require rapid assessment and decisionmaking by hospitals to determine if they can handle the volume of patients
presenting for evaluation and treatment.
Patient Evaluation and Triage Centers
Asymptomatic individuals with perceived (worried-well) or real exposure are
likely to present to hospitals for medical evaluation and information, and may
comprise the majority of individuals who utilize medical services. Hospitals are
responsible for including in their disaster plans alternative locations outside the
emergency department for triaging, assessing and providing necessary treatment
to these individuals, so that critical resources can be devoted to individuals with
significant injury or illness and prevent contamination of emergency department
spaces. Alternatively, patients may be directed to the Mass Dispensing Sites that
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will maintain the provision for assessing the concerns of the worried well and
dispensing of antibiotics and vaccines as necessary. Further, citizens may be
directed by Unified Command to shelter in place (i.e. school, workplace) or
remain at home until otherwise instructed.
These alternative locations are referred to as Patient Evaluation and Triage
Centers and will be able to accommodate large numbers of individuals. These
centers include ambulatory services within or near the hospital campuses,
auditoriums or other hospital health system sites, as well as public health clinics.
These resources may be operated by a combination of existing hospital staff and
volunteer2 physicians and nursing personnel who can provide these evaluations.
Unified command will communicate the location of these facilities through the
local media and/or the Emergency Alert System (EAS) notification system.
Tracking of Patients Evaluated and Triaged
Individual institutions that operate these centers (both private and public) will
keep track of all persons evaluated and triaged. These records will include
receiving hospital information for patients triaged to in-patient care. Unified
command will work with the Patient Evaluation and Triage Centers to ensure that
there are appropriate records to allow for an estimate of case counts and
exposed individuals. Unified command will collect patient data daily from these
centers.
Mass Hospital Patient Care
Expansion of Acute Care Capacity
Biological events involving 1-100 casualties, 100-10,000 casualties, and >10,000
casualties will require different responses. Depending on hospital resources and
how rapidly the influx of patients occurs it is anticipated that events involving
less than 100 individuals may be handled using existing hospital resources. In
larger situations, patient triage and evaluation capacity may greatly exceed the
capacity required to provide acute medical care.
Nontraditional Treatment Centers
An epidemic that overwhelms all hospital resources may require the rapid
establishment of Nontraditional Treatment Centers to provide advanced care to
people in need of hospitalization, region wide. Where possible these centers will
be located in unused space in hospitals or sites near hospitals. Examples of
possible locations for Nontraditional Treatment Centers include long-term care
facilities and other healthcare facilities (e.g., former hospitals either vacant or
2
Refer to page 16 under the heading “Spontaneous Volunteers” for guidelines on
credentialing/licensure information
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used for other purposes), hotels and dormitory facilities that may be vacant (or
vacated), convention centers, the Cleveland I-X Center, community colleges,
various sports arenas or other large venues in the region. Also, hotels currently
in operation will be considered as well since they have room and bed availability.
If necessary unified command may request the U.S. Military to assist with rapid
deployment of field hospitals.
The Center for Health Affairs will conduct a periodic survey to determine hospital
space availability and its condition. This information will be available for use by
unified command.
These improvised Nontraditional Treatment Centers may be under administrative
direction from the city, county, state or federal administration if the hospitals are
unable to provide oversight. When feasible these centers will be located near
hospitals to facilitate transport of more acute individuals to locations where
certain specialized care is provided.
Stable patients may be evacuated to regional institutions, according to NDMS
procedure. Based on public health directives the cohorting of patients with
similar illness may be necessary, depending upon the infection control
requirements of the biological agent causing disease.
Hospital Daily Reporting
Traditional (hospitals) and nontraditional treatment centers involved in caring for
victims of the epidemic or bioterrorist event will communicate with the Center for
Health Affairs representative at the EOC each day to report daily number of
unoccupied beds (including respiratory isolation capacity), as well as all
equipment, supply and staffing needs. Each hospital has identified one individual
to serve as its Emergency Coordinator. This person is responsible for
communicating this information to the Center for Health Affairs.
Sharing of Staff and Supplies
Unified command will respond to staffing and supply shortages by arranging for
state (e.g., National Guard) or Federal assistance. Examples include the
Strategic National Stockpile Program that includes ventilators, antibiotics and
other medical supplies, and the federal Disaster Medical Assistance Teams
(DMAT), which provide trained medical personnel. Hospitals have been
encouraged to utilize existing staff and contracts with pharmaceutical distributors
before requesting external assistance.
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Forward Movement of Patients - National Disaster Medical System
(NDMS)
An event leading to 10,000 or more casualties may prompt activation of the
National Disaster Medical System (NDMS) support in the form of DMATs and the
forward movement of patients to other cities.
A specific protocol3 describes in detail the elements of moving patients from
hospitals within the region to other local communities, counties, regions or states
in order to create available bed space to increase patient surge capability of
hospitals in the affected county(s).
Quarantining
Certain infectious diseases may require quarantine in hospitals or other
institutions, or confinement to homes or personal residences. The State of Ohio
and local communities are discussing options for quarantining individuals and
communities. This will likely require changes in existing law in order to address
the modern day challenges of quarantining persons. Regional public health
partners are currently developing a quarantine plan.
Per Ohio Revised Code the local and/or county health departments may order
the isolation or quarantine of individuals with a communicable disease, or
individuals who are reasonably suspected of having, or carrying or being exposed
to a communicable disease. The local and/or county health departments may
also prescribe destruction and/or impounding of personal effects, and
disinfection of a private residence of persons found to have a communicable
disease.
Quarantine recommendations will likely be voluntary, although they may require
enforcement. Local law enforcement, if necessary, will assist in enforcement of
the quarantine. Immunized health care workers will provide the needed medical
care/basic services to individuals who are quarantined, either in homes or other
facilities.
Counties from within the region will assist with quarantine in affected counties
that request it. The affected local and/or county health departments are
responsible for making contact with the health departments that will be
requested to help. Unified incident command will assist as necessary.
Mass Fatality Management
3
Attachment B – Northeast Ohio Forward Movement of Patients Protocol
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In the event of a large-scale emergency, multi-casualty incident, disaster or
terrorist attack the County Coroner’s Office will implement its Disaster Response
Plan. Additional refrigerated vehicles will be brought in if needed.
Counties from within the region will assist with the mass fatality management in
affected counties that request it. The affected local and/or county health
departments are responsible for making contact with the health departments
that will be requested to help. Unified incident command will assist as necessary.
Jurisdiction for Fatalities
The County Coroner will retain jurisdiction of all fatalities resulting from the
release of a biological weapon. The local and/or county health departments and
Ohio Department of Health will retain jurisdiction of fatalities resulting from a
naturally occurring infectious disease outbreak.
Hospital deaths from confirmed or suspected infectious agents due to Bioterrorism will be reported to the Coroner. The bodies will be brought to the
Coroner’s Office or a location designated by the Coroner for examination
following established safety procedures by the Coroner or her designated
Pathologist. If decontamination is necessary prior to transportation of bodies,
permission must be obtained prior to doing so. This will ensure that critical
evidence is not destroyed by the decontamination procedure. The decision to
perform an autopsy will be at the discretion of the Coroner. If the Coroner’s
Office morgue is at capacity, the Coroner will make a decision to use temporary
morgues.
Deaths due to bio-terrorism related infectious agents outside of a hospital setting
would be transported to the Coroner’s Office or to a temporary morgue by the
Coroner’s transportation services or by those authorized by the Coroner.
Augmentation of morgue capacity will include the use of refrigerator trucks, and
if necessary, ice rinks. State and federal resources will be requested to provide
needed equipment and staffing for this expansion.
State and federal resources (DMORTS) will be requested in consultation with the
Coroner to provide supplies (e.g., body bags, autopsy equipment, etc.), staff
(e.g., autopsy technicians, pathologists, administrative staff) or transportation if
the number of fatalities exceeds the capacity of the Coroner’s Office.
The Coroner will be responsible for collection and transportation of body fluids
and/or tissue samples to a Microbiology Laboratory (state or CDC) in accordance
with chain of custody procedures. The Coroner, maintaining a registry of similar
deaths, will determine a cause and manner of death.
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Data regarding all deaths will be entered into the existing Coroner’s database,
according to established policies and procedures. This database will be used to
track all incident-related deaths.
Following procedures approved by the Coroner (taking into account the need for
infectious disease precautions) viewing of the body to allow for identification of
the deceased will be permitted if feasible. If need be other methods such as
photographs, dentition, fingerprints, x-ray and DNA will be utilized. All of the
Coroner’s Office policies and procedures regarding notification of next of kin will
be followed.
In the event of a mass disaster resulting in harmful contamination to human
bodies, the county health departments, through the Coroner’s Office in order to
protect the public health from the release of potentially dangerous remains, shall
determine and proceed with the safest disposition of such bodies without having
to receive permission from the next of kin. If there is no contamination or risk of
disease transmission, bodies will be released to funeral directors, according to
current Coroner’s Office procedure.
Standard operating procedures regarding universal precautions for blood and
body fluids, infection control and isolation will be used for autopsies and the
handling of corpses. The Coroner’s Office and hospitals within the NEO Region
have standard procedures for these activities.
If mass decontamination is necessary, HAZMAT or DMORT team(s) called in to
assist will establish mass decontamination facilities with direction from the
Coroner’s Office to decontaminate prior to autopsy or burial. Individual hospitals
may utilize hospital-based decontamination facilities for this same purpose.
The County and/or State Health Director, in conjunction with the Coroner, may
determine that cremation or temporary use of mass grave is necessary to protect
the health of the public because of either the volume of deaths or contagious
etiology of illness. In this event, the Coroner’s Office will direct hospitals and
funeral directors to cremate corpses or transport to a designated location for
temporary burial.
The NEO Regional Steering Committee and Ohio Department of Health will use
their existing communications network so that information regarding autopsy
procedures, diagnosis and final disposition of the deceased is conveyed as
quickly as possible. This network will rely on broadcast fax, e-mail and posting
information on local, state and federal websites to disseminate this
communication. In addition, the NEO Regional Steering Committee and Ohio
Department of Health will work with the various County Funeral Directors
Associations to develop rapid systems of communication so that funeral directors
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throughout the region have immediate access to recommendations for care of
the deceased.
The NEO Regional Steering Committee and Ohio Department of Health in
conjunction with the Coroner’s Office will work with the funeral directors and
religious leaders to develop plans for group funerals and memorial services as
well as grief assistance mechanisms for survivors. The NEO Regional Steering
Committee and Ohio Department of Health will also work with the religious
community to address the possibility of a catastrophic epidemic that may result
in significant mortality.
The Coroner’s Office will use its existing grief assistance program to provide
support for bereaved survivors. If these services require additional capacity, the
Coroner will request state and federal resources to supplement. Additional
collaborations with the American Red Cross, the NEO Regional Steering
Committee, other volunteer organizations (Hospice Organizations, Cuyahoga
County Mental Health Board), and County Critical Incident Stress Management
(CC-CISM) will be used to expand access to this service.
Environmental Surety
The public health departments, HAZMAT resources, the U.S. Environmental
Protection Agency (EPA) and other agencies may assess environmental health
risks. As necessary, these agencies identify environmental health risks, assess
the need for control measures, conduct environmental investigations, determine
the need for mitigation and management, and recommend appropriateness of
reentry.
The Federal Bureau of Investigation (in the event of suspected bioterrorism),
and/or the HAZMAT resources, the U.S. Environmental Protection Agency (EPA),
public health departments and other agencies will be responsible for collecting,
packaging and testing samples. The collection, packaging and transportation of
environmental specimens will be done in accordance with existing agency
procedures that assure both safety and chain of custody. Samples will be
forwarded to the ODH laboratory.
The local and county resources supported by the ODH if necessary will perform
Control/disposal of animals or biological vectors.
Counties from within the region will assist with environmental surety in affected
counties that request it. The affected local and/or county health departments are
responsible for making contact with the health departments that will be
requested to help. Unified incident command will assist as necessary.
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Training, Education and Exercise Plan
This plan4 describes the approach to providing training, education and exercises
for first responders, health and hospital professionals in the NEO Region. It
incorporates training that has already occurred in the region and establishes
minimum expected training for all those who will be involved in response to a
biological incident. This plan calls for a regular program of continuing education
and exercises to reinforce and test this plan.
4
Attachment C – Northeast Ohio Region Training, Education and Exercise Plan
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