After action report tabletop exercise

After Action Report 

Tabletop Exercise: 

Long Term Care Mutual Aid Plan (LTC-MAP) 

for Evacuation & Resources / Assets 

Scott Aronson 

Russell Phillips & Associates, LLC 

31 Cooke Street 

Plainville, CT 06062 

T: 860-793-8600 

www.phillipsllc.com 

March 4, 2010 

A service of the King County Healthcare Coalition and 

Public Health Seattle & King County 

www.mutualaidplan.org/kingcountywa

After Action Report/Improvement Plan King County Healthcare Coalition 

(AAR/IP) LTC-MAP Evacuation and Resources / Assets Plan 

ADMINISTRATIVE HANDLING INSTRUCTIONS 

1. The title of this document is the King County Long Term Care Mutual Aid Plan 

(LTC-MAP) for Evacuation & Resources / Assets. 

2. The information gathered in this AAR/IP is classified as For Official Use Only and 

should be handled as sensitive information not to be disclosed. This document 

should be safeguarded, handled, transmitted, and stored in accordance with 

appropriate security directives. Reproduction of this document, in whole or in 

part, without prior approval from King County Healthcare Coalition is prohibited. 

3. At a minimum, the attached materials will be disseminated only on a need-toknow 

basis and when unattended, will be stored in a locked container or area 

offering sufficient protection against theft, compromise, inadvertent access, and 

unauthorized disclosure. 

4. Point of Contact: 

Lydia Ortega 

Healthcare Coalition Administrator/Business Manager 

PUBLIC HEALTH │ SEATTLE & KING COUNTY 

401 5th Ave., Ste. 1300, Seattle, WA 98104 

206.263.8721 p │ 206.296.0166 f 

lydia.ortega@kingcounty.gov 

Danica Mann 

Training and Exercise Manager 

King County Healthcare Coalition 

206.947.5565 

Danica.mann@overlakehospital.org 

Administrative Handling Instructions 2 King County Healthcare Coalition



Contents 

Administrative Handling Instructions ..................................................... 2 

Contents..................................................................................................... 3 

Executive Summary .................................................................................. 4 

Section 1: Exercise Overview .................................................................. 6 

Exercise Details.......................................................................................................... 6 

Exercise Planning Team & Planning Meetings .......................................................... 7 

Participating Organizations ........................................................................................ 7 

Section 2: Exercise Design Summary..................................................... 8 

Exercise Purpose and Design .................................................................................... 8 

Objectives, Capabilities & Activities ........................................................................... 9 

Scenario Summary..................................................................................................... 9 

Exercise Format ....................................................................................................... 11 

Section 3: Analysis & Performance Improvement ............................... 12 

Section 4: Conclusion............................................................................. 22 

Contents 3 King County Healthcare Coalition



Executive Summary 

Although rare, evacuation of a healthcare facility is a complex event requiring significant 

coordination throughout the local community and the extended region. An evacuation of 

this extent necessitates both internal and external planning. The success of an 

evacuation is dependent on the effectiveness of internal procedures, external 

relationships and cooperation/coordination with other healthcare facilities and 

community emergency responders. A unified and coordinated response is essential. 

This tabletop exercise activated the internal nursing home evacuation procedures, 

initiated interaction with the Public Health Duty Officer and the Health & Medical Area 

Command (HMAC), activated the King County Long Term Care Mutual Aid Plan and 

tested the surge capacity / Influx of Patients process for the receiving healthcare 

facilities. 

This After Action Report (AAR) is designed to analyze exercise results, identify 

strengths to be maintained and built upon, identify potential areas for further 

improvement, and support the development of corrective actions. 

Major Strengths 

The major strengths identified during this exercise are as follows: 

� Activation: The plan was generally activated following the activation protocol 

in the Long Term Care Mutual Aid Plan (LTC-MAP). 

� Coordination: Each Disaster Struck Facility was prepared with their internal 

steps for the evacuation plan, evacuation sites and a current Transportation 

Evacuation Survey prepared for EMS / Fire. 

� Communication: The communication between the Disaster Struck Facility 

and Patient Accepting Facilities plus the Health & Medical Area Command 

and the Disaster Struck Facility was well established. 

� Influx / Surge: Receiving facilities provided a sound foundation for their 

actions and thought process to prepare for a patient influx / surge. 

� Tracking: Patient tracking was successful. Participants utilized tracking 

forms and communication channels to relay patient information. The goal 

was to understand where the patients were sent compared against the master 

list of patients, and this process was included. 

Primary Areas for Improvement 

Several opportunities exist for improvement in the King County’s ability to conduct an 

evacuation. The primary areas for improvement are as follows (see Analysis of 

Exercise for detailed recommendations): 

� Communications: Clearly delineated communications on responsibilities need 

to be established early between the HMAC and the Disaster Struck Facility as 

Executive Summary 4 King County Healthcare Coalition



to what resource each requires and who they will be communicating with. 

This coordinating of roles and responsibilities between the Disaster Struck 

Facility and coordinating support group (EOC / HMAC / etc.) were discussed 

but could pose a substantial challenge to concise communications with the 

Patient Accepting Facilities if not formally pre-established (i.e. HMAC will deal 

with all Patient Accepting Facilities and the Disaster Struck Facility will deal 

with management of the incident and communications with EMS / Fire onscene.) 

� Documentation: The LTC-MAP plan provides extensive information and 

multiple forms. While forms were discussed in general terms, there is a 

learning curve to using the forms and the database to retrieve information. 

� Patient Tracking: Clearly and accurately documenting on the appropriate 

tracking forms and ensuring all forms end up in the appropriate location – 

Disaster Struck Facility Command Center, Patient Accepting Facility or 

HMAC. 

� Education: Education of leadership and staff at the facilities on use of the 

LTC-MAP, the forms and how to handle an incoming call from a Disaster 

Struck Facility or HMAC. 

As appropriate, staff should continue to be educated on the: 

o Resident Evacuation Tracking Forms 

o Patient/Medical Record and Equipment Tracking Sheet 

o Incoming Patient Log 

o Disaster Struck Facility and HMAC Aggregate Tracking Forms 

o Utilization of the LTC-MAP database to retrieve information 

o Role of the HMAC 

o Internal activation/notification procedures 

Executive Summary 5 King County Healthcare Coalition



Exercise Details 

SECTION 1: EXERCISE OVERVIEW 

Exercise Name 

King County Long Term Care Mutual Aid Plan (LTC-MAP) for Healthcare 

Evacuation and Medical Surge 

Type of Exercise 

Tabletop 

Exercise Start Date 

4 March 2010 

Exercise End Date 

4 March 2010 

Duration 

Approximately 2 hours with 3 additional hours of education incorporated 

Location 

Tukwila Community Center, Tukwila, WA 98168 

Sponsor 


Program 

Regional Catastrophic Grant Program 

Mission 

Response 

Capabilities 

Medical Surge (Disaster Struck Facility / Patient Accepting Facilities / 

Communications 

Scenario Type 

Healthcare Evacuation 

Section 1: Exercise Overview 6 King County Healthcare Coalition 

For Official Use Only



Exercise Planning Team 

Henk Straatman 

Life Care Center of West Seattle 

Seattle, WA 

Mark Weise 

Providence Mount St. Vincent 

Seattle, WA 

Lydia Ortega 

Public Health Seattle & King County 

Seattle, WA 

Danica Mann 


Seattle, WA 

Long Term Care Mutual Aid Plan Task Force / Special Expertise Committees 

Scott Aronson 

Russell Phillips & Associates, LLC 

Plainville, CT 

Planning Meetings 

October 28, 2009 – Initial Planning Conference (Task Force Meeting) 

December 15, 2009 – Intermediate Planning Conference (Public Health) 

February 26, 2010– Final Planning Conference (Disaster Struck Facilities) 

Participating Organizations 

� Public Health Seattle & King County 

� King County Healthcare Coalition 

� Seattle Fire 

� King County Metro 

� Life Care Center of West Seattle (Disaster Struck Facility) 

� Providence Mount Saint Vincent (Disaster Struck Facility) 

� Multiple representatives from Patient Accepting Facilities 

Number of Participants 

• Controllers: 1 

• Evaluators: 4 

• Players: 30 

Section 1: Exercise Overview 7 King County Healthcare Coalition 

For Official Use Only



SECTION 2: EXERCISE DESIGN SUMMARY 

Exercise Purpose and Design 

The emphasis of this exercise was to implement the King County Long Term Care 

Mutual Aid Plan (LTC-MAP) for Evacuation and Resources / Assets via the evacuation 

of multiple healthcare facilities. Additionally, the exercise was designed to introduce the 

plan to all of the regional long term care facilities, emergency management directors, 

EMS, Fire, State and other regional groups that may not have been exposed to the 

LTC-MAP during the design phase while providing practice on implementing the plan 

and an opportunity to improve that plan during the Tabletop Exercise. 

The focus was on properly coordinating the activation of the plan, set-up of the internal 

full building evacuation plans, coordination of regional communication via the Health & 

Medical Area Command (HMAC), tracking patients and supporting the surge capacity 

plans at each of the patient accepting facilities. 

This exercise was initiated with the decision to evacuate a single facility and concluded 

with the confirmation of patients being received at the Patient Accepting Facilities. 

This exercise involved the following tables: 

� Health & Medical Area Command / Long Term Care Coordinating Team (1 table) 

� Disaster Struck Facilities (1 table) 

� Patient Accepting Facilities and Transportation (2 tables) 

Please note that the artificialities with time during the exercise were designed to 

eliminate primary discussions about all of the steps that would be taken to avoid the 

need to evacuate and focus on the evacuating taking place. Discussions did take place 

at the Disaster Struck Facilities about steps they would be completing concurrently to 

re-establish their facilities to re-open and accept patients. 

Section 2: Exercise Design Summary 8 King County Healthcare Coalition



Objectives, Capabilities, and Activities 

There were several objectives for this exercise: 

Overarching Objectives 

1. Activation: Upon the start of the exercise, utilize the activation/notification 

procedures within the King County LTC-MAP. 

2. Communication: Communicate appropriately between the Disaster Struck Facility, 

Health & Medical Area Command (HMAC), Local Emergency Responders, 

Department of Social and Health Services (DSHS), and Patient Accepting Facility. 

3. Tracking: Ensure that patients are tracked throughout the entire process, from the 

Disaster Struck Facility to the Patient Accepting Facility. 

4. Medical Surge: Provide from the Disaster Struck Facility (DSF) consistent, accurate 

and relevant health and medical information to clinicians and other responders about 

patients being evacuated in an organized and timely manor and internal facility 

surge process. 

Disaster Struck Facilities (Facilities being evacuated) 

1. Communication: Ensure the facility being evacuated communicates appropriately 

to contact local 911/emergency responders, Public Health Duty Officer, HMAC and 

Patient Accepting Facilities. 

2. Tracking: Use LTC-MAP tools, communication channels and documentation to 

ensure that patients are tracked to each Patient Accepting Facility. 

Health & Medical Area Command (HMAC) / Long Term Care Coordinating Team 

1. Communication: Ensure appropriate communication with the Disaster Struck 

Facility and have communication channels established with local EOCs as 

necessary and Patient Accepting Facilities. 

2. Planning: The HMAC will utilize administrative tools within the King County LTC- 

MAP to support the evacuation and patient placement / tracking. 

Patient Accepting Facilities 

1. Communication: Ensure the Patient Accepting Facility communicates appropriately 

to maintain contact with the HMAC and/or Disaster Struck Facility. 

2. Tracking: Use King County LTC-MAP communication channels and documentation 

to ensure that patients are accounted for at the Patient Accepting Facility and patient 

status is reported to the HMAC or the Disaster Struck Facility. 

3. Medical Surge: Ensure that internal plans are implemented and documented for 

Influx of Patients / Surge Capacity Plans. 




Scenario Summary 

Situation / Status Report 1: 3/4/2010 at 1:00 PM 

Due to a severe weather emergency, Life Care Center of West Seattle has lost their 

HVAC capabilities. The facility is being forced to evacuate with the support of Seattle 

Fire and private EMS companies. The decision has been made to activate the Long 

Term Care Mutual Aid Plan to support resource coordination and establishing Patient 

Accepting Facilities. The facility had a current census of 83 patients with 11 requiring 

EMS transport (BLS Ambulance), 49 needing wheelchair accessible vehicles and 23 

that could go by any means of transport. 


While the initial evacuation is going smoothly and the facility, along with EMS, have preselected 

the healthcare facilities where all of the patients will be placed, another 

situation has arisen. Providence Mount St. Vincent has experiences sprinkler pipes 

bursting on the top 2 floors causing extensive internal damage. They are moving to 

immediately relocate patients to other buildings on campus as Stop Over Points and are 

requesting support to evacuate higher acuity patients first, followed by temporary 

locations to place their other nursing home patients. The facility had a current census of 

210 patients with 7 requiring EMS transport (BLS Ambulance), 159 needing wheelchair 

accessible vehicles and 44 that could go by any means of transport. Additionally, on 

campus they had another 109 residents in Assisted Living (14 requiring wheelchair 

accessible vehicle and 95 that could go by any means of transport) and 14 Adult Day 

Health Care residents (7 requiring a wheelchair accessible vehicle and 7 that could go 

by any means of transport.) Overall, there was the potential that 333 total 

patients/residents may have to be fully evacuated. 

The situation is forcing the Health & Medical Area Command, along with Seattle Fire, to 

re-evaluate where the patients could be moved to and ensure that each evacuating 

facility coordinates centrally through the group. 


Each facility has been receiving incoming patients/residents from the evacuating 

healthcare facilities and reporting this information back to either the Disaster Struck 

Facility or the Health & Medical Area Command (depending on which group they were 

told to contact). While the evacuations will take several more hours to complete, the 

pre-designation of evacuating sites has been completed and the HMAC is able to 

coordinate effectively by utilizing the LTC Coordinating Team. 




Exercise Format 

This was a Tabletop Exercise. The exercise began with a scenario for all participants. 

Roles and Responsibilities 

• Players respond to the situation presented based on their experience and the new 

Long Term Care Mutual Aid Plan (LTC-MAP) for Evacuation and Resources / 

Assets. 

• The Controller provided situation updates and moderated discussions. The 

Controller also provided additional information or resolved questions as required. 

• Evaluators did not participate in the discussion, but were present for the duration of 

the exercise gathering data and writing notes about the players’ responses in order 

to provide feedback for the exercise After Action Report (AAR). 

• A Hotwash was conducted for 30 minutes at the conclusion of the exercise. 

Assumptions and Artificialities 

In any exercise, a number of assumptions and artificialities may be necessary to 

complete play in the time allotted. During the exercise, the following apply: 

• The scenario is plausible, and events occur as they are presented. 

• There are no “hidden agendas” or trick questions. 

• All players receive information at the same time. 

• The simulation of time passing may be accelerated or delayed as appropriate by the 

exercise controller. 

Assumptions 

• Players are familiar with LTC-MAP following their education on the plan. 

• Exercise players include senior leadership from the King County Healthcare 

Coalition and the LTC-MAP Task Force, who are empowered to create a new or 

modify any existing plans and policies, if necessary. 




SECTION 3: ANALYSIS AND PERFORMANCE IMPROVEMENT 

This section of the report reviews the performance of the exercised capabilities, 

activities, and tasks. Each activity is followed by related observations, which include 

references, analysis, and recommendations. As any plan member could be the 

Disaster Struck or Patient Accepting Facility during a real activation, these observations 

are relevant to all plan members. 

HMAC = Health & Medical Area Command 

EOC = Emergency Operations Center 

I. Internal Healthcare Facility Command Center (Disaster Struck 

Facility): 

1. Observation – Incident Command System improvements: The application of 

Incident Command System needs to be reviewed and enhanced at long term 

care facilities. It has been identified that staff need continuous education on what 

the Incident Command System is and how the positions and communications will 

work internally and externally. This would include having a formal Incident 

Commander and Command Staff position (Liaison, Safety / Security, Public 

Information Officer) and Section Chiefs (Operations, Logistics, Planning, Finance 

/ Administration). 

Recommendation: All facilities should incorporate incident command into their 

plans. This includes having a Table of Organization and Job Action Sheets to 

use as a checklist during a disaster. Further exercises and training for facilities in 

Incident Command is needed. 

A number of incident command trainings can be found on-line through FEMA. A 

few samples of the programs are listed below: 

� The links below lead to ICS courses for Healthcare. This site is run by FEMA, 

and each course should take approximately 2-4 hours, plus a post-test. They 

are offered at no cost, and certificates of completion will be provided. 

� Introduction to ICS: 

http://training.fema.gov/EMIWeb/IS/is100HC.asp 

� National Incident Management System 

http://training.fema.gov/EMIWeb/IS/is700a.asp 

� Applying ICS to Healthcare: 

http://training.fema.gov/EMIWeb/IS/is200HCa.asp 

� Additionally, there is free training through Yale that is healthcare specific. 

These programs are EM108 (equivalent to FEMA 700 level course for 

Section 4: Conclusion 12 King County Healthcare Coalition



introduction to the National Incident Management System) and EM142 

(equivalent to ICS 100 and 200): 

� http://ynhhs.emergencyeducation.org/ 

2. Observation – Use of the LTC-MAP manual: The Disaster Struck Facility 

should become familiar with the flow of the LTC-MAP hard copy plan to ensure 

effective use during a disaster. 

Recommendation: All plan members should consider internal education on the 

LTC–MAP plan for Nursing Supervisors, leadership and managers so there is a 

baseline understanding of how to use the plan. 

II. Communications with (Disaster Struck Facility, HMAC, EOC, 

Patient Accepting Facility, Media): 

3. Observation – HMAC to Disaster Struck Facility: Health and Medical Area 

Command (HMAC) and the Disaster Struck Facility should establish early on in 

the incident the division of duties to avoid duplication of calls and actions. 

Recommendation: There should be early communications between HMAC and 

the Disaster Struck Facility and establish a briefing timeframe. It should be 

determined which organization is speaking with the Patient Accepting Facilities, 

families and other agencies. 

If HMAC manages the calls, then a regional call center may be setup. 

4. Observation – Disaster Struck Facility / Patient Accepting Facility and the 

Media: Facility specific plans should include reference to Public Information 

sharing. Working with the HMAC and On-scene fire/EMS will ensure that there is 

one message going out from all plan members to the Media. 

Recommendation: Long term care facilities should ensure there is a person 

internally designated as the Public Information Officer (PIO) to manage all 

messages being used internally to educate staff and externally with HMAC, the 

media and community partners. See LTC-MAP plan in Annex I, Section 4, #10 




5. Observation – HMAC to EOCs: During a large scale incident, there is a need to 

coordinate situational awareness information between HMAC and EOC’s about 

facilities that fall within their jurisdiction. This might include local EOCs 

assessing facilities based on criteria established by HMAC and reporting to 

HMAC on their status. HMAC would then aggregate the situation updates and 

distribute regionally to all EOC’s and healthcare partners throughout the event. 

Recommendation: HMAC should coordinate with local EOC’s to develop 

protocols on assessing healthcare facilities within their jurisdiction. 

III. Activation/Notification: 

6. Observation – Internal Facility Notification Process: The internal process for 

notifications within a receiving facility needs to be clearly defined so facilities are 

positioned to respond. 

Recommendation: Staff members should be educated what to do if a call is 

received from a Disaster Struck Facility or if a WATrac alert is received. It is 

recommended that facilities create a quick reference guide/sheet providing 

detailed instructions to anyone that may be in the position to receive an outside 

call or message, on or off-hours. 

7. Observation – WATrac Communications - Challenges: The LTC-MAP 

facilities are not yet active on WATrac and therefore the only method to stand up 

the plan is by phone. 

Recommendation: Russell Phillips & Associates will provide Public Health 

Seattle & King County with all data to load the information into WATrac so that 

facilities can be alerted through WATrac. Following the importing of 

information, education should take place with LTC-MAP members on use of the 

system. 

8. Observation – Disaster Struck Facility Communication to Public Health 

Duty Officer to Activate the Plan: It was identified that clear and concise 

methods need to be instituted to contact the Public Health Duty Officer to activate 

the plan. This needs to be accompanied by clear communication about the 

incident. 

Recommendation: When a Disaster Struck facility communicates with the 

Public Health Duty Officer, they should be prepared to communicate the following 

information: 

� Who – Your contact name and direct phone number during the 

incident 

� Where – Facility Name and Town/City 




IV. Patient Tracking: 

� What – Evacuating or Potential to Evacuate 

� When – Imminent or window of time 

� Why – Reason 

9. Observation – Education on Tracking Sheets/Disaster Tags: Players were 

not always familiar with how to incorporate the use of the Resident Evacuation 

Tracking Forms and the Patient/Medical Records and Equipment Tracking Sheet. 

Additionally, an Influx of Patient Log form was provided for facilities to consider 

as an internal tool for receiving patients – designed to complement the existing 

Tracking Sheets/Tags. 

Recommendations: 

a. Provide the Resident Evacuation Tracking Form to staff members during 

training to help familiarize them with filling out the tags and the method for 

attaching them to patients. 

- The Healthcare Coalition should coordinate with plan members to print 

this form in triplicate and distribute appropriate amounts to each 

healthcare facility. 

b. Plan members should provide the Patient/Medical Records and Equipment 

Tracking Sheet to all nursing and leadership team members that could be in 

the capacity to send the patients out of the Disaster Struck Facility or receive 

them at the Patient Accepting Facility. 

- The Healthcare Coalition should coordinate with plan members to print 

this form in triplicate (1 stays with the Disaster Struck Facility, 1 copy with 

EMS and 1 copy to the Patient Accepting Facility) and distribute 

appropriate amounts to each healthcare facility. 

c. There will always be Just-In-Time training that is necessary during an 

emergency or disaster. Ensure core groups of staff are very familiar with the 

tracking components of the plan so they can help familiarize their colleagues. 

d. At the Patient Accepting Facility, Influx of Patients forms should have copies 

made, with the master copy staying with the patient and the copy going to 

the Command Center. If these forms are printed as duplicate or triplicate, it 

will solve this issue without having to make copies. 

e. At the Disaster Struck Facility and HMAC, the Aggregate Patient Tracking 

Tools should be printed on 3ft wide by 2ft high on dry erase board laminate. 

- Healthcare Coalition should coordinate with plan members to print this 

form for each healthcare facility Command Center and the EOCs / HMAC. 




10. Observation – Clinical Needs of the Patients for Tracking: Although this 

exercise did not involve simulated patient care, in a real activation, the Disaster 

Struck Facility would need to communicate clinical patient information to the 

Patient Accepting Facility, if possible. 

Recommendation: The Disaster Struck Facility should attempt to designate a 

clinical staff member (Operations Section Chief) to coordinate with the Liaison 

Officer and insert them as the primary point-of-contact with the HMAC/EOC 

and/or Patient Accepting Facility, to ensure medical information is properly 

communicated. Appropriate medical record and medications lists should 

accompany the patient. 

Matching the correct patient with the correct facility is important. 

11. Observation – Barcode Labels: A patient tracking system, such as bar-code 

labels, was discussed as necessary to more effectively track the patients. 

Recommendation: The Healthcare Coalition and Public Health Seattle & King 

County should consider the implementation of a patient tracking system, that 

might include barcode labels with tracking numbers for each patient at each 

facility. 

12. Observation – Top Ten List: Facilities did not have a detailed preplanned 

listing of their “top ten” locations where they would like to evacuate to in a 

disaster. 

Recommendation: Each long term care facility should review the plan members 

and other facilities that are not plan members, and select the appropriate 

facilities, based on the LTC Facility Information Report and Special Categories of 

Care Report, that can handle their patients’ clinical needs and total number of 

patients. This should be entered directly into the database under Evacuation 

Sites. 

V. Command & Control: 

13. Observation – Steering Committee / LTC Coordinating Team: Individuals 

should be selected from the overall group to operate as the Steering Committee 

to manage the overall plan on a quarterly basis. This group would also have 

members that are responders to the HMAC to be the voice of the long term care 

community in a disaster. 

Recommendation: Several individuals signed up to be members of the Steering 

Committee and be responders. There will need to be a team of 12 individuals 




comprised with an even balance of Administrators, Nursing and Support 

Services. This team will require additional Incident Command System training on 

how to interact with the HMAC and EOCs as well as having Job Action Sheets, 

forms and tools to coordinate the LTC-MAP. Public Health Seattle and King 

County has contracted Russell Phillips & Associates to develop this process and 

create tools for HMAC and for responders. 

14. Observation – Decision-making on Patient Destinations: In a single facility 

incident, the facility will be working directly with the Patient Accepting Facilities to 

place patients and will utilize support from the Health & Medical Area Command 

(HMAC), Fire/EMS and local EOCs as necessary. There was confusion in a 

multiple facility incident as to how decisions on placement will take place. 

Recommendation: In a multiple facility incident, the Disaster Struck Facilities 

will still be organizing and making initial planning decisions on where their 

patients will be transferred. The difference in how the incident will operate is that 

the information will flow up to the HMAC and verifications will be made about if 

those facilities are designated for other incoming patients or if they are impacted 

by the disaster and are no longer able to accept patients. HMAC is providing 

coordinating support along with the Long Term Care Coordinating Team 

(responders) to ensure that the Disaster Struck Facility is aware of the regional 

impact due to the emergency. Russell Phillips & Associates has been contracted 

with to operationalize this process. 

15. Observation – Incident Action Plan: Individual members of the EOC teams 

needed additional prompting in how to prepare an Incident Action Plan and some 

additional focus areas in supporting a regional disaster. 

Recommendation: In developing an Incident Action Plan, staff should consider 

addressing the following: 

• Developing an Incident Action Plan 

o What do we need to do? 

o Who is doing it? 

o What is necessary to stabilize the Incident? 

o How do we communicate (to DSF, to emergency responders, to 

DPH, to PAFs)? 

• SALT (words to live by in coordinating an evacuation) 

o Size (# of patients) of the Disaster Struck Facility(ies)? 

o Amount of Resources Necessary to Evacuate the Facility (types of 

transportation required, unique patient requirements)? 

o Location of Pick-up for Patients? 

o Time to get them out (how fast are they evacuating)? 




VI. General: 

16. Observation – Patient Accepting Facility Actions: We would like to 

complement the Patient Accepting Facilities that were able to fully discuss their 

Influx of Patients plan as they reviewed the process upon entry to their facility. 

Recommendation: Please continue to share your experiences in fully activating 

with all members of the LTC-MAP plan as facilities continue to improve their 

internal plans. One improvement will be that Russell Phillips & Associates will be 

providing a best practices guidelines on how to surge. This will be made 

available the summer 2010. 

� Sample of how another out-of-state facility surged: 

o Received and communicated to all staff quickly and all staff on alert 

o Education information posted on daily board for staff to review 

o Set-up beverages/food station, pillows/blankets/fans, puzzle books 

for entertainment 

o Appropriate medical supplies, tools for assessment of 

temperature/pulse/respiration and privacy curtains put in place 

o Supportive devices – wheelchairs/walkers/canes, close proximity to 

the restrooms, services to support patients 

o Pastoral Care / Psych – Emotional support in place 

o Communications – Phones for incoming patients to speak with 

families 

o Buddy system established for incoming patients for support 

o Charts started with paperwork for care plans, mini mentors / 

associates 

o Chapel converted into triage – area with medical supplies, 

equipment and comfort measures 

o Executive Director spoke directly with the Mayors Office for 

Emergency Preparedness to review the overall experience. 

o Recommendation: Other than perishable, have all of the supplies 

necessary to receive your appropriate number of patients in a 

supply closet or other location – clean, stacked and ready to go. 

Overall a wonderful learning experience and the ED was able to 

learn first hand about the dedication and caring of her staff for 

people in need. 

17. Observation – Surge Capacity: It was identified in several organizations that 

several issues pose a challenge in expanding to 110% of licensed beds: 

� Multiple facilities referenced concerns with getting enough equipment to 

support a surge (beds being the primary) 

� Concern was raised about needing a Waiver from DSHS to surge 

Recommendation: All are good comments. Long term care facilities typically 

are not involved in surge capacity and therefore do not have processes to 




accomplish a surge. 

For the equipment, it is important to note what you specifically need to be able to 

surge to the number requested of you. Work as a group to understand the 

resources each facility has and what can be provided by HMAC or your local 

emergency management agency. 

Finally, for the waiver, an approach is being presented to DSHS based on what 

some other states are doing. DSHS has reviewed the plan and provided support 

for the plan, which included the surge approach to 110% of licensed beds. If 

approved, documentation will be provided to update the plan. 

18. Observation – Healthcare Facility-owned Transportation Assets: With the 

healthcare facilities having a high volume transportation capability to assist the 

Disaster Struck Facility(ies), it was determined that there may be coordinating 

challenges around transportation and clarification needed on what information 

should be provided to the Disaster Struck Facility / HMAC / Emergency 

Responders. 

Recommendation: The facility-owned vehicles should be utilized in the 

following ways once the plan is activated: 

� Patient Accepting Facilities should be prepared to provide a status update 

on available vehicles in the following manner: 

o Time when the vehicles will be available and for how long. 

o Type of vehicles that will be available in that window of time. 

o Determination as to whether or not your facility will be able to pick 

up the patients that are coming to your facility and provide a clinical 

team member to support the transfer. 

� If picking up, Patient Accepting Facilities will need be provided with the 

location of the staging area where you will pick-up patients 

� When the incident is over, the vehicles should be used to help Disaster 

Struck Facility get their patients, staff and equipment back to their facility 

19. Observation – Offering Additional Beds to EOC or Disaster Struck Facility: 

One facility posed the question “At what point can we offer additional beds?” 

Recommendation: There are 2 times that a facility should offer additional beds: 

� When the facility is formally being notified that it will be receiving patients. 

� If, early on in the incident, your facility can handle a significant amount of 

additional beds (not 2 or 3 more, that would take place at the 1 st bullet, but 

8 – 10 or so), this should take place by calling the Disaster Struck Facility 

(or HMAC if it is operational) once it is verified that the facility is 

evacuating. 




20. Observation – Exercises: Several members expressed interest in running an 

exercise with the physical movement of Mock Patients to other healthcare 

facilities and the activation of the LTC-MAP to support those efforts. 

Recommendation: Further training on the LTC-MAP is needed throughout King 

County prior to a drill of this magnitude occurring. Following the appropriate 

training and tabletop exercises, the Healthcare Coalition will work with 

participating facilities to determine a date. Funding availability and regional 

exercise calendaring will impact the timing of this drill. 

21. Observation – Best Practices / “Go Kit”: A facility “go-kit” be made available 

to receive incoming patients and support evacuation. 

Recommendation: All facilities should consider adopting and having a pre-set 

go-kit for receiving patients from another healthcare facility, or if evacuating. 

Below are some recommendations for the development of a go-kit: 

The go-kit could be put in one labeled container or plastic tote bag with handle 

and include: 

� Wristbands (enough for the maximum amount or patients facility could 

receive in a disaster or that could need a wristband when evacuating) with 

blank labels 

� Permanent markers and pens 

� Thermal “lunch” tote with 3 cold packs, in case medications need 

refrigeration during transport of patients from one facility to another 

� Gallon sized Ziploc bags that are tamper evident (need to tear the bags 

once sealed) for meds with blank labels 

� Disposable camera for patient photos 

� Resident Emergency Evacuation Tracking Forms (enough for the entire 

patient population) 

� Patient/Medical Record & Equipment Tracking Sheets (1 sheet for every 3 

patients should be available in this container) 

� Influx of Patients Log (take the number of slots on each form and 

determine how many would be necessary for an influx – usually 2 – 4 

forms) 

� Flashlight and extra batteries 

� Duct Tape (just because you could need this for anything ☺) 

� Any other internal tools used for your Emergency Operations Plan 

22. Observation – Recovery: Securing your facility if you have evacuated: A 

discussion arose about what security is needed after your facility has been 

evacuated. 

Recommendation: The facility should work with local emergency management 

and police to have someone stationed at the facility until private security can be 




brought in to monitor the site. Security contracting should be established by 

facilities in advance with appropriate groups for verification of rates and 

references for the security company. If unable to do this in advance or the group 

is unavailable, working through the local emergency operations center would be 

the appropriate next step. If this is unsuccessful, the request should go through 

Health & Medical Area Command as a specific need for the organization. 

Facilities should not assume that local law enforcement will be able to provide 

security for any particular length of time. 

23. Observation – EMS / Fire / Emergency Management Participation: There 

was limited participation by emergency responders in the education on the plan. 

Recommendation: Pull together the leadership for each within King County and 

request a forum to introduce the components of the plan and methods in which 

each facility has constructed their specific pieces to the plan. 

Additionally, each facility should meet with their local groups and discuss their 

specific elements to the plans at their facility. This information has been provided 

in the Attachment to the LTC-MAP plan referencing Local and Regional 

Contacts. 

24. Observation – DSHS emergency phone voicemail: The phone line for DSHS 

is not monitored 24/7 so healthcare facilities are concerned that their emergency 

call will not be heard in a timely manner. 

Recommendation: Healthcare facilities should continue to report emergency 

situations to the phone line as part of the DSHS protocol, but utilize the Public 

Health Duty Officer at the local level for immediate assistance (outside 911). 

Each healthcare facility can work with their licensor directly to determine if there 

is a better number for calling DSHS during an emergency. 




SECTION 4: CONCLUSION 

This exercise successfully addressed all of its objectives as outlined in the report. This 

provided an excellent opportunity for the long term care facilities to come together for 

the first time in an exercise. Many facilities in the region have experienced a disaster 

either internally, locally or regionally in the past years and the Long Term Care Mutual 

Aid Plan concept is solidifying a process for preplanned resource & assets as well as 

evacuation support. The group is prepared to “go live” with this plan if it was necessary 

to implement at any time in the near future with the exception of addressing the formal 

activation process and having the final forms printed to support patient tracking. 

By focusing on strengthening patient prioritization for location and transfer, the 

coordinating team / Steering Committee, communication systems and the coordination 

of resources, King County will continue to make great progress in its all-hazards 

emergency management planning and ability to successfully defend a long term care 

facility in place or, in a worst case scenario, evacuate one or multiple regional facilities.

After action report tabletop exercise

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