Alternate Care Facilities Functional Annex

State: CO Type: Model Practice Year: 2015

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Hospitals face concerns about shortages in healthcare professionals and high facility usage. Area hospitals average 80-90% occupancy on a daily basis. This condition makes medical surge in facilities beyond capacity a high possibility in a pandemic scenario or a bioterrorism incident with long term response and recovery operations.  Tri-County Health Departments goal was to develop a Alternate Care Facility Annex to support the TCHD Public Health Emergency Operations Plan (PHEOP) in a way to help impacted partners establish an agreed upon plan for identifying surge capacity within the hospital system and when this capacity may be over-extended, establish ACFs to help manage surge when the scope of any disaster becomes too large or long-term for the existing infrastructure to handle, and create and support a seamless system of healthcare surge capacity throughout Adams, Arapahoe, Douglas, and Elbert Counties that is able to respond effectively and efficiently to public health emergencies of a pandemic nature. 

 

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Tri-County Health Department
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Alternate Care Facilities Functional Annex
Tri-County Health Department (TCHD) serves a diverse population totaling approximately 1.3 million people from its 11 different offices across Adams, Arapahoe, and Douglas counties, making it the largest local health department in Colorado. The geography of this 3000 square mile jurisdiction includes both densely populated areas and rural communities. TCHD also provides support to neighboring Elbert County with a population of approximately 23,000 people. Within these four counties there are twelve hospitals with emergency departments and five specialty hospitals. Hospitals face concerns about shortages in healthcare professionals and high facility usage. Area hospitals average 80-90% occupancy on a daily basis. This condition makes medical surge in facilities beyond capacity a high possibility in a pandemic scenario or a bioterrorism incident with long term response and recovery operations. The goals of the Alternate Care Facility (ACF) Functional Annex to the TCHD Public Health Emergency Operations Plan (PHEOP) are to:• help impacted partners establish an agreed upon plan for identifying surge capacity within the hospital system and when this capacity may be over-extended, • establish ACFs to help manage surge when the scope of any disaster becomes too large or long-term for the existing infrastructure to handle, and• create and support a seamless system of healthcare surge capacity throughout the four Counties that is able to respond effectively and efficiently to public health emergencies of a pandemic nature. Planning began in the City of Aurora between the hospitals, the office of emergency management, local EMS providers, and TCHD. Once a final draft was completed and evaluated through exercises, the document was used as a template for the counties served by TCHD. In 2010 it was determined that a single ACF Functional Annex covering the entire TCHD jurisdiction would be more effective. The planning group now includes the original partners as well as behavioral health, coroners, pharmacies, and other ESF #8 partners. This Annex was adopted in November 2011 and updated to include facility specific appendices. The document was tested using an exercise series including all key partners culminating in a functional exercise on April 17, 2014. The process used to develop this annex included a traditional planning and exercise cycle as well as a response to a real-world incident. The hospitals in the city were originally looking for assistance in resource prioritization, guidance on altered standards of care and liability, and support in command and control for long term incidents. Once the resulting plan was passed to county authorities as a template for their own efforts, additional challenges were identified through exercises, specifically around medical liability, resource leveraging, and command and control. The height of early planning efforts coincided with the response to the H1N1 pandemic. Using findings from this experience and from the exercise series it was determined that rather than be housed with county offices of emergency management, the alternate care facility plan would be written, managed and exercised by TCHD with support from all stakeholders. TCHD has taken the lead in addressing this gap in medical surge planning for catastrophic, long term incidents. The TCHD ACF Functional Annex directly addresses issues regarding long term medical surge identified by the hospitals in the jurisdiction and those posed by behavioral health, coroners, emergency management, and other stakeholders. By coordinating efforts in the early stages of an incident, the response system is allowed time to explore options, develop an appropriate strategy for response, and be proactive during incidents. Sites are pre-designated for use but the annex allows for flexibility. Finally, the document addresses concerns regarding liability, resource prioritization, altered standards of care, and the decision making process for clinical and operational issues. There are three primary factors that have contributed to the success of this project. The initial gap was identified by hospitals within a defined jurisdiction and prioritized by decision makers within those facilities. Planning was conducted as a coordinated effort involving a cross section of stakeholders from the disciplines that would be impacted by this type of intervention during a long term public health incident. Finally the planning group has and continues to demonstrate flexibility in the development of the document and operational structure. This Annex was written to assist with long term medical surge including resource management and command and control. Through planning and exercise efforts, it was determined that a single command structure for multiple counties and municipalities assisted in the prioritization and leveraging of the likely scarce resources needed in the response efforts. The impact on this issue is a more streamlined and efficient plan for managing this aspect of a public health crisis. Tri-County website http://www.tchd.org/  
As described in the Public Health Preparedness Capabilities, medical surge is the ability to provide adequate medical evaluation and care during events that exceed the limits of the normal medical infrastructure of an affected community and to assist in the recovery of that healthcare system. The functions associated with this capability charge public health agencies to assist in the:• assessment of the nature and scope of the incident,• support of the activation of medical surge,• support jurisdictional medical surge operations, and• support demobilization of medical surge operations. Hospitals are required by the Joint Commission and other certifying bodies to have plans in place to accommodate surge above their normal capacity for up to 96 hours. This requirement allows hospitals to manage short term incidents in an efficient manner until the majority of patients are treated and discharged. The gap recognized by these hospitals was in their preparedness for long term biological or pandemic events requiring patient care for an extended time period.The Tri-County Health Department (TCHD) Alternate Care Facility (ACF) Functional Annex was written to assist local partners in the identification of possible long term medical surge associated with a pandemic or other like biological incident or agent and to guide the incident command structure through the decision making process as to the proper intervention. Additionally, the annex provides the command and control structure for the activation and operation of one or multiple alternate care facilities managed by a single command structure. Through planning and exercise efforts, it was determined that a single command structure for multiple counties and municipalities is most effective for the prioritization and leveraging of the likely scarce resources needed in the response efforts. In this instance, the local health department with support of emergency management, law enforcement, hospitals, behavioral health, coroners, and other stakeholders has been identified as the entity in command. Tracking and demobilization of resources would be accomplished in this command structure to ensure appropriate accountability. The target population affected by this issue includes the 12 hospitals with emergency departments, the additional five specialty hospitals, ambulatory surgical centers, long term care facilities, home healthcare agencies and other types of medical businesses and the patients in which they serve within the TCHD jurisdiction. Because this appendix was written, tested, and approved by the disciplines most impacted by its implementation, roughly 90-95% have been reached by its approval. A catastrophic emergency, such as a large-scale bio-attack, a natural disaster, or a severe influenza pandemic, will likely overwhelm hospitals and other traditional healthcare facilities. Alternate care facilities are locations that can be or are set up for the care of large numbers of patients in the event that hospitals become overwhelmed. Examples of possible locations, or facilities used in the past include schools, sports stadiums, and conference centers that can be prepared and used for the care, feeding, and holding of large numbers of victims of a mass casualty or other type of incident. Such improvised facilities are generally developed in cooperation with a local hospital. While hospitals remain the preferred destination for all patients, during a disaster/ incident, such improvised facilities may be required for a specific time period in order to divert low-acuity patients away from hospitals.There is a long history of providing medical care in nonhospital settings dating back to the Civil War, the influenza pandemic of 1918, and, more recently, in the aftermath of Hurricane Katrina. However, most of these operations were conducted as just-in-time tactics in response to an incident rather than being a pre-planned response to a threat. There are no alternate care facility or other like plans available through the NACCHO model practice database and a number of questions remain unanswered that need to be addressed before conducting this type of intervention:• What would be the scope of care and the types of patients best treated in this nonhospital setting?• What type of facility would be appropriate, what equipment would be required? • And, most importantly, who would take care of the patients in such a facility at a time when medical staff in hospitals, clinics, and emergency departments will be stretched thin by increased numbers of patients and absenteeism among their ranks?For the purposes of our annex, we have narrowed down the use of an ACF for long term and on-going incidents such as a pandemic. An ACF takes too long to set up to be used in a mass casualty/trauma incident and the types of care required by this type of patient would likely be beyond the scope of this setting. The TCHD ACF Functional Annex directly addresses the issues regarding long term medical surge identified by not only the hospitals in the jurisdiction, but also those posed by behavioral health, coroners, emergency management, and other key stakeholders. The Annex specifically walks through communications and the coordination of efforts by entities within the TCHD jurisdiction. By beginning coordination efforts in the early stages of an incident, the response system is allowed time to explore possible options, develop an appropriate strategy for response, and to be proactive in response to events as they develop. If deemed necessary, the Annex also outlines how to activate an ACF, the command and control structure for the incident and individual ACFs, necessary staffing and supplies, and recommended levels of care. Sites are pre-designated for use in this intervention, but the plan allows for flexibility given the specifics of an incident. Finally, the document addresses concerns regarding liability, resource prioritization, altered standards of care, and the decision making process for clinical and operational issues. The current proposed practice has gone through continuous revisions since the initial plan was developed in 2006. Some of these revisions were in direct relation to the feedback from participating response partners during previous drills and exercises while other components have been updated based on changing laws, requirements, and expectations. Additional revisions to the Annex include communication updates based on the availability and use of online situation awareness used by supporting response partners. These communication tools efficiently relay essential information which include resource request notification from hospitals within the TCHD jurisdiction and requests for assistance for resources and information sharing with local emergency management. Improvements to the Annex from the last scheduled functional exercise also focused on the Medical Branch Section and the implementation of concepts around patient acuity levels, triage process, patient care at each of the ACF locations, and staffing issues. This practice is a creative use of an existing tool or practice. There is a long history of providing medical care in nonhospital settings. However, this Annex utilizes this concept to extend medical care for low acuity patients of multiple hospitals throughout multiple local jurisdictions under the command and control of a single health department. This system works to leverage resources in response to a long term medical surge scenario. Through initial and ongoing planning efforts, no research on alternate care facility documents has identified an existing plan for an ACF managing patients from multiple hospitals and hospital systems crossing jurisdictional boundaries. Though tools exist for alternate care facility planning and matrices for staffing and site identification have been developed, these items are not intended to be used as operational documents. The TCHD ACF Annex lays out a unique approach to leveraging resources for a more effective and efficient use of staffing and supplies likely to be limited during a long term biological incident. Additionally, the TCHD ACF Annex was developed to address issues regarding altered standards of care, liability, a unique strategy for staffing support, and the concerns of all Emergency Support Function (ESF) #8 stakeholders within the three counties. ESFs are a mechanism for grouping functions most frequently used to provide support during an incident. ESF #8 pertains to all functions related to health and medical response. Public health practitioners are experienced in taking the lead in disease control and impact mitigation during response to large scale outbreaks impacting a community. However, in recent years the role of public health has expanded with the implementation of the federally defined Emergency Support Functions (ESFs) and most specifically ESF #8 – Health and Medical. Public health agencies have shifted into not only performing traditional public health roles during incident response, but are now also coordinating and supporting all portions of the health and medical system. This new expectation has pushed public health into assuming a more prominent leadership role in emergency management as a whole. The ACF Functional Annex was drafted and has been tested in coordination with a broad cross section of emergency management, health, and medical partners with this new reality in mind. Local public health would be serving as either incident command or part of the unified command structure of any incident large enough to require the implementation of an ACF. Traditional response partners would shift into coordinating and supporting roles, focusing on their own specific responsibilities, while public health manages the operational momentum of this complicated response tactic.
The goals of the Alternate Care Facility (ACF) Functional Annex to the TCHD Public Health Emergency Operations Plan (PHEOP) is:• to help emergency managers, pre-hospital agencies, hospitals and Tri-County Health Department establish an agreed upon plan for immediately identifying surge capacity within the hospital system, and for identifying when such capacity may be rapidly over-extended, • to establish Alternate Care Facilities as needed to help manage surge capacity when the scope of any disaster becomes too large or long-term for the existing infrastructure to handle, and• to create and support a seamless system of healthcare surge capacity throughout Adams, Arapahoe, Douglas and Elbert Counties that is able to respond and provide care effectively and efficiently to public health emergencies of a pandemic nature, from small, but significant incidents to large-scale catastrophic disasters. The scope of the ACF Annex is to provide a system that allows for the triage, treatment and disposition of 50 to 500 adult and pediatric patients, with acute illness from a catastrophic pandemic or like event. This facility would function primarily as an overflow site for hospital patients requiring low acuity medical care and scalable upward for massive incidents. The annex identifies primary locations in each of the counties served by TCHD that can be utilized individually or simultaneously to serve as ACF locations. With enough staff and the ability to find locations, we could set up facilities to accommodate almost any number of patients. The number of facilities TCHD is able to support is completely resource dependent. Any patients requiring more than basic medical interventions would not be served by an ACF. The Medical Branch, made up of appropriate representatives from participating hospitals and other technical specialists, determine the level of care in an ACF based on the symptomology of the illness and the resources available for use in the facility. It is important to note that the Annex outlines specific triggers that must be met in order to make the use of an ACF an appropriate intervention. These triggers include the inability to identify possible alternate treatment facilities (i.e., nursing homes, long term care facilities, surgical centers, etc.) in the local area as well as across the state, the inability of surrounding states to support patient care in nearby hospitals, and the inability of the National Disaster Medical System to support the movement of patients around the nation to provide in-hospital care of affected patients. A situation of a magnitude large enough to require an ACF would also warrant altered standards of care as well as a Public Health Declaration of Disaster and a Stafford Act Declaration of Disaster. These altered standards of care are determined by the Governor’s Office, the Governor’s Expert Emergency Epidemic Response Committee (GEEERC), and the Colorado Department of Public Health and Environment. The TCHD Command Structure would work through any additional clinical care decision that may be required and the criteria for admission and levels of care would be continuously evaluated throughout the incident and modified collaboratively as conditions warrant. The specific tasks taken to achieve the goals and objectives of this document were to: 1. Develop a planning group made up of the appropriate technical experts2. Develop a useable plan addressing the major gaps in alternate care facility planning 3. Educate and get buy-in from all key agency leadership4. Exercise and improve the Annex on an ongoing basis. The initial development of this Annex began in the City of Aurora, Colorado between the hospitals in that municipality, the office of emergency management, the local EMS providers, and TCHD. Once a final draft was completed and evaluated through exercises, the document was used as a template for the three counties served by TCHD. In 2010 it was determined that a single ACF Functional Annex covering the entire TCHD jurisdiction would be more efficient and effective. The planning group now includes the original partner disciplines from throughout the jurisdiction as well as behavioral health, coroners, pharmacies, surgical centers, and other ESF #8 partners. After six years of development, this Annex was adopted as being in final draft form in November 2011 and began the evaluation and improvement process. This Annex has been tested through an exercise series with participants from all of the counties, partner agencies, and the state health department culminating in a functional exercise held in April 2014 that required the staffing of all portions of the command structure to address a broad range of issues posed by the implementation of an alternate care facility. The steps taken to implement create, exercise, and adopt this annex included:o Research existing plans to identify information useful to our situationo Develop planning groupo Create and edit initial drafto Small scale exercises to test drafto Edit documento Education of leadership/buy-in/feedbacko Identify primary locations/touro Update plan by adding specific appendices to outline each of the three ACF facilitieso Large Table Top Exercise( TTX)o Edit document based on findingso Functional Exercise – April 17, 2014o AAR Report summarizing Functional Exercise findingso Edit document based on findingso Develop improvement plan and schedule drills/exercise based on objectives from response issues list Through the exercise cycle, there were many lessons learned that contributed to improving the document. Staffing for Alternate Care Facilities when hospitals are already in a state above capacity will be a challenge in any response. The planning group worked to create an agreement whereby hospitals must provide a limited number of staff to the ACF in order to send patients. This creates a buy-in to the facility while also meeting a critical need. Another example of a lesson learned is in regards to patient status once transferred to a shared ACF and the storage of patient records. Through our planning process, it has been determined that despite some drawbacks, patients at the ACF will remain the patient of the originating hospital until they are released to go home. At that time they will be discharged as in accordance with their hospitals procedures and all patient records will be returned to the originating hospital to be maintained and stored according to hospital operating procedures. These two examples reflect some of the detailed concerns in establishing an intervention of this nature. Though many decisions cannot be made until the incident occurs, the planning group has made a thorough attempt at identifying potential issues in advance to be better prepared to address them. It is difficult to set a timeframe for the completion of the tasks associated with a project of this nature. There is no hard deadline for the completing ton this annex as we strive for continual improvement. The ACF Planning Group, comprised of technical experts from hospitals, behavioral health, emergency management, pharmacies, law enforcement, fire, and other disciplines from throughout the TCHD jurisdiction, has a core of committed stakeholders that have been meeting for multiple years; however, content experts have joined the group as needed. Once TCHD accepted the responsibility of maintaining the Annex, the planning group established an 18 month timeframe ending in November 2011 for the development of a useable final draft of the TCHD ACF Annex. At this point, the Annex moved into the exercise cycle for testing and improvement. This process included seminars for educating partners and leadership on the annex and to gather feedback from these partners in November 2011, and then the development and implementation of a tabletop exercise in June 2012. On April 17, 2014 a functional exercise was scheduled and the results of the exercise have begun to drive the planning efforts based on the Improvement matrix outlined in the After Action Report (AAR). Each step in this process includes time to analyze feedback and implement necessary changes or additions. Stakeholders to this Annex have played an integral role as discipline content experts on the ACF Planning Group. They have worked to reveal gaps in the planning process, identify information and resource needs, and provide technical expertise to address challenges. These stakeholders have educated their internal agency or facility partners on the Annex, gathered support and approval from leadership, recruited participants for exercises and assisted in addressing improvement items. In a response capacity, these stakeholders will fill out the command structure, serve as liaisons with their home agency or facility, and assist in the decision making processes. Despite this being a long term and effective collaborative effort, there have been some barriers to the planning process. When working with a large and diverse group, the topic of medical surge in a long term situation is not often the priority for most planning partners. It has been a disaster heavy year in Colorado and planning efforts have been stifled by real-world response to incidents of a vastly different nature. And finally, the legal implications of an intervention of this nature initially caused some trepidation during initial planning efforts. This ACF Planning Group is a subcommittee of the larger TCHD Healthcare Coalition. This is one example of how this long standing network of partners collaborates on emergency preparedness and response efforts. The Healthcare Coalition meets on a quarterly basis to exchange information and ideas and to give updates on projects. The ACF Planning Group meets quarterly for planning efforts, exercise design, and to exercise components of the annex. There have been few costs associated with the development of the Annex beyond the staff time dedicated to planning groups, actual writing of the document, and participation in exercises. TCHD receives Public Health Emergency Preparedness (PHEP) grant money from the Centers for Disease Control and Prevention (CDC) through the Colorado Department of Public Health and Environment (CDPHE) that funds staff time to facilitate the ACF planning process. The majority of hospital partners participating in this effort receive Hospital Preparedness Program (HPP) money, through the Office of the Assistant Secretary for Preparedness and Response (ASPR), to supplement their emergency preparedness efforts. Behavioral health agencies that have provided valuable input into the ACF Annex all receive some emergency preparedness grant funding from CDPHE to assist in funding their preparedness and response activities.
The overarching goals of the Alternate Care Facility (ACF) Functional Annex to the TCHD Public Health Emergency Operations Plan (PHEOP) are:• to help emergency managers, pre-hospital agencies, hospitals and Tri-County Health Department establish an agreed upon plan for immediately identifying surge capacity within the hospital system, and for identifying when such capacity may be rapidly over-extended, • to establish Alternate Care Facilities as needed to help manage surge capacity when the scope of any disaster becomes too large or long-term for the existing infrastructure to handle, and• to create and support a seamless system of healthcare surge capacity throughout Adams, Arapahoe, Douglas and Elbert Counties that is able to respond and provide care effectively and efficiently to public health emergencies of a pandemic nature, from small, but significant incidents to large-scale catastrophic disasters. Specific objectives were developed to test the operationalization of the Annex through a series of exercises. These objectives included:1. Illustrate triggers and procedures for the activation of the TCHD ACF Annex2. Define stakeholder roles and responsibilities in a medical surge event3. Identify planning gaps in the TCHD ACF Annex to be addressed by the TCHD ACF Planning Group4. Demonstrate communication between all stakeholders and the activation sequence prior to opening an alternate care facility (ACF)a. Determine if communications should occur between TCHD and individual hospitals or hospital systemsb. Evaluate the triggers indicating the need for an ACFc. Review and validate the required actions prior to the opening of an ACF5. Evaluate resource mobilization and coordination for ACFs between federal, state, and local partnersa. Specifically identify the need for and sources of specialized equipment (i.e. pediatrics and behavioral health)b. Explore staffing issues to meet specific patient needs (i.e. pediatrics, geriatrics, increasing level of care)c. Demonstrate how behavioral health staff will support the Medical Branch in determining what types of needs will be supported at ACF locations and how they will staff those positions. The Annex is continually evaluated through the Homeland Security Exercise and Evaluation Program (HSEEP) compliant exercise cycle. HSEEP is a capabilities and performance-based exercise program that provides a standardized methodology and terminology for exercise design, development, conduct, evaluation, and improvement planning. Leadership and operational partners throughout the TCHD jurisdictions participated in an educational seminar on the Annex, tested the Annex through a large scale table top exercise, and, after further refinement, simulated the command structure for the implementation of this Annex through a functional exercise. Stakeholders walked through a pandemic scenario, which has stayed consistent throughout the exercise series, to test primary components and decision making processes as well the ability to problem solve around medical, technical and logistical questions anticipated in a real-world incident. Assigned evaluators were able to observe specific responses as they related to the exercise objectives and collect feedback during the exercise hotwash sessions. The findings from these exercises as well as participant feedback were incorporated into extensive after action reports and improvement matrices detailing observations, recommendations, action items, points of contact for the actions, and a timeframe for completion. All exercises associated with the Annex will follow the same HSEEP compliant process and end with an after action report and detailed improvement matrix. The Annex is continually evaluated through the Homeland Security Exercise and Evaluation Program (HSEEP) compliant exercise cycle. HSEEP is a capabilities and performance-based exercise program that provides a standardized methodology and terminology for exercise design, development, conduct, evaluation, and improvement planning. Through a large scale functional exercise stakeholders walked through a pandemic scenario to test primary components and decision making processes. Participant data from the ACF functional exercise conducted on April 17, 2014 includes the following:1. The functional exercise consisted of 13 exercise goals and objectives,2. Thirty-five injects were designed to drive exercise participation in evaluating the identified goals and objectives, and 3. There were 52 exercise participants from 14 different response agencies. Assigned evaluators are defined to observe specific responses as they relate each of the exercise objectives and collect feedback during the exercise hotwash/debrief. The findings from the exercise as well as the feedback are incorporated into an extensive after action report and improvement matrix detailing observations, recommendations, action items, points of contact for the actions, and a timeframe for completion. All exercises associated with the Annex will follow the same HSEEP compliant process and end with an after action report and detailed improvement matrix. All members of the ACF Planning Group and the member of the TCHD Healthcare Coalition receive copies of the After Action Report and Improvement Matrix for all scheduled exercises. The lessons learned during each exercise supported the operations outlined in the Annex. Those items identified as areas of improvement are detailed in the improvement matrix with a responsible agency and point of contact listed as well as a timeline to complete the necessary task. TCHD staff track the improvement matrix to ensure these items are addressed within the allotted period of time. The functional exercise, through progressive injects geared to test specific portions of the Annex, supported the content of the Annex. There were a number of areas, such as communications, Medical Branch section role and responsibilities, and regional command and control that were identified as needing more detail in the body of the document. The findings were detailed in the after action report and specific responsible parties were identified in the improvement matrix with a timeline for completion. Based on the AAR and lessons learned from the April 17, 2014 ACF Functional Exercise, there were a number of areas the Annex will be modified to improve processes based on the objectives outlined and injects designed to test specific portions of the plan. Modifications to the plan will target the following areas to improve collaboration between all supporting agencies: 1) continue to train staff and develop objectives for future drills and exercises to test WebEOC and EMResource systems with supporting response partners, 2) continue to utilize the ACF planning group as a platform to clarify roles and responsibilities for each agency involved in a response, and 3)identify medical concerns for both healthcare facilities and ACF locations through planning and exercises and implement these concepts under the Medical Branch Section of the Annex.
Through the exercise cycle, there have been many lessons learned that have worked to improve the document. Staffing for Alternate Care Facilities when hospitals are already in a state above capacity will be a challenge in any response. The planning group worked to create an agreement whereby hospitals must provide a limited number of staff to the ACF in order to send patients to an ACF. This creates buy-in to the facility while also meeting a critical need. Another example of a lesson learned is in regard to patient status once transferred to a shared ACF and the storage of patient records. Through our planning process, it has been determined that despite some drawbacks, patients at the ACF will remain the patient of the originating hospital until they are released to go home. At that time they will be discharged as per their hospitals procedures and all patient records will be returned to the originating hospital to be maintained and stored according to hospital operating procedures. These two examples reflect some of the detailed concerns in establishing an intervention of this nature. Though many decisions cannot be made until the incident occurs, the planning group has made a thorough attempt at identifying potential issues in advance to be better prepared to address them. TCHD learned, once again, that it takes an extensive amount of coordination and collaboration with a large number of key stakeholders to truly make a response annex functional. We all worked closely together over the course of many years to ensure we could gain the buy in and support from all partners, in a variety of disciplines and subject matter areas of expertise, all the way up to the executive decision making level. Now the end result is an annex that is operational and has the full support of all key stakeholders who would benefit from the activation of this annex. The only costs associated with continued maintenance of the Annex are that of staff time and efforts related to exercise implementation. As this planning effort is part of day-to-day emergency preparedness functions, costs will be absorbed into routine operating budgets. Exercise resources will be leveraged by testing multiple annexes or plans to ensure that specific components of the plan are exercised alongside other emergency preparedness and response activities. Evaluation of the Annex included the development and execution of the ACF functional exercise which was tested on April 17, 2014. Additionally, position specific trainings for ACF volunteers will be offered annually to provide continuing education for nonclinical staff. Because this planning process was originated in 2006, there has been a demonstrated commitment by stakeholders to continue the process and to refine the plan. Through the original planning efforts as well as TCHD has taking the lead role in the ACF planning process there have been many staff changes within TCHD and other participating agencies. The fact that these agencies continue to support the effort reflects the buy-in from leadership, the dedication to the project, and the sustainability of the process. Additionally, though the intent of this Annex is to address the worst case scenario long term medical surge incident, elements of the Annex have been used in real-world incidents, thereby proving to partners the importance of the process and the Annex. The only costs associated with continued maintenance of the Annex are that of staff time and efforts related to exercise implementation. As this planning effort is part of day-to-day emergency preparedness and response functions, costs will be absorbed into routine operating budgets. Exercise resources will be leveraged by testing multiple annexes or plans to ensure that specific components of the plan are exercised alongside other emergency preparedness and response activities. Continued evaluation of the Annex includes the development and execution of additional exercises which will focus on specific needs that were observed during the April 17, 2014 functional exercise and any other future responses.
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