What is PMESII-PT that this speaker mentioned? 

• That was one of the frameworks, using complex operational planning, larger context and always trying to memorize and refer to political military economic social information infrastructure, physical environment and time. 

How likely are concurrent or subsequent cyberattacks in future engagements? Which sectors are most likely to be targeted initially? 

• Compound attacks, often involving two vectors and potentially multiple actors depending on the adversary's sophistication, are likely, especially from state-sponsored terrorists or adversaries, who might employ multi-domain operations (as the military would). The confluence of events like COVID, a hurricane, and a deep freeze in Louisiana/Texas a few years ago, while natural, illustrates the potential for significant disruption. A cyberattack exacerbating such natural disasters could cause substantial physical harm, hinging on the attacker's cyber capabilities. However, such a threat is unlikely to manifest without a significant political context. Electricity is a primary concern due to its pervasive reliance, with network systems presenting both resilience and vulnerabilities. The lack of electricity, exemplified by the absence of backup generators in hospitals, could severely impede essential care.

Using your frameworks and aside from external threats, are there internal systemic issues in the medical realm that you see as vulnerabilities?

• Highly complex and efficient supply chains are essential, especially for time-sensitive pharmaceuticals requiring strict temperature control and minimal error margins. Tight deadlines and fundamental costs must be balanced to effectively deliver public health services. Consider other aspects of supply chain resilience.

Is part of the solution to approach the threat from the other direction.... To reconsider the nature design and frequency of mass gatherings with these threats in mind... or is that both defeatist and unrealistic?

• Mass gatherings reflect our inherent desire to connect and share experiences. While these events aim to be enjoyable, their design involves a tradeoff. Operationally, is the goal to maximize throughput like a BK or Wendy's model with multiple lines, where efficient design ensures quick entry and exit? Further consideration should be given to clearly defining authority for large venue designs.

How does Public Works (water - potable / palatable)  fit into the Cybersecurity and Infrastructure Security Agency (CISA) approach with safeguards?

• Water, one of 16 critical infrastructures, faces security and resilience challenges due to its small and distributed nature and limited budgets. Assistance is needed to address threats from nation-state actors. A general approach to water security should consider the ability to withstand adverse effects and recover. The American Waterworks Association (AWA) is relevant to water system resilience. Research is needed on a law concerning six-year-olds.

The emphasis on continuity should always be on critical or essential missions - those functions, capabilities and actions that cannot be suspended. Accordingly, do those mission essential functions need to be defined for an organization prior to beginning to work continuity of operations?

• Focus on assets rather than their function. While people need water, the delivery system must be efficient. Recognize that during emergencies, alternative systems might fulfill essential functions. Consider utilizing two distinct sources to enhance the Community Resilience Planning Framework (CRPG) or its guidance, as well as the Infrastructure Resilience Planning Framework (IRPF). How can these elements be effectively integrated?

When thinking of potable water, remember that those that make ice (vendors, etc.) would need to be contacted immediately during boil water advisories and orders. Also, grocery stores would need to be advised to order additional bottle water.

• Ice is important, fisheries part of the economy, not just to prevent heat exhaustion, but also to get the economy up and running for the county.

Does CISA have an accessible communication channel for sharing medical security intelligence with private sector hospitals?

• Information on setting up accessibility centers (ISAC) includes considering electricity, natural gas, and Health and Human Services/Assistant Secretary for Preparedness and Response (HHS/ASPR) or other relevant entities. HHS provides substantial information, accessible through assistant representatives, email, or local advisors who can be contacted via a system.

Inquire about the number of Disaster Medical Assistance Teams (DMATs) and Disaster Mortuary Operational Response Teams (DMORTs), their training frequency, and funding sources.

• There are 40 Disaster Medical Assistance Teams (DMATs) nationwide, each with 38 personnel including medical professionals, support staff, and administrators. Monthly, 10 teams are on call. Additionally, 10 Disaster Mortuary Operational Response Teams (DMORTs) in five regions can provide mass mortuary care; while historically deployed less often, they assisted with events like the Maui wildfires and the Potomac plane crash. A veterinary response team also exists within this framework to support large, small, and service animals during National Security Events (NSEs). 

Do you use the National Incident Management System (NIMS) for actual organization, communication, and operations? 

• Upon deployment, all HHS incident management team members with operational control must complete necessary paperwork and Incident Action Plans (IAPs) in a NIMS-compliant manner. 

What are the main challenges limiting interoperability between federal, state, and local responders when facing health threats at mass gatherings, and what actions could be considered to strengthen it? 

• The difficulty lies in reaching the event due to time and distance constraints. However, the federal government possesses the capability to monitor (biorelease) and trace back to HHS for mass prophylaxis if necessary, distributing countermeasures from the national strategic stockpile through HHS to state and local levels.

Are you looking at a national bed tracking system so the data could be seen at the federal level in addition to the regional level?

• There has been increased interest in bed tracking. While complex, NDMS (Patient Movement section) offers some capabilities using primarily raw data. Monthly tests ping hospitals for their willingness to accept patients during disasters. In the event of a natural disaster or operation, we can request bed counts to identify regions with the most availability and facilitate patient transfers.

Does the U.S. Department of Health and Human Services (HHS) have any locations in Puerto Rico? 

• The organization has teams in the continental US, Puerto Rico, Hawaii, and Alaska, as well as some overseas (OCONUS) teams. The OCONUS teams are smaller due to their voluntary nature; members become intermittent federal employees. These teams can deploy locally and nationally with other teams, drawing from a smaller population in potential threat areas. 

How should we contact you to request your participation in a future exercise?

• Contact Katie Watson, NCR Regional Coordinator at Constitution Center. For engagement with ASPR, reach out to the ASPR Regional Coordinator (online or via the state department of health). We are always eager to share our capabilities and participate in planning and exercises. You can find all the Regional Emergency Coordinators at https://aspr.gov/rec  

The Administration for Strategic Preparedness and Response (ASPR) provides HPP program grants to develop local healthcare coalition capabilities (communications, decontamination, mass casualty management, etc.). Has consideration been given to incorporating local HCCs and utilizing their resources? 

• Within the Administration for Strategic Preparedness and Response (ASPR), the office for mass gatherings operates differently. Their Cooperative Agreements and grants include ASPR input for funding recommendations, aligning with our views on advancements in Large-Scale Combat Operations (LSCO) areas and identifying where state and local entities should receive financial support. 

Could you elaborate on the existing inter-hospital emergency patient transfer protocols during disasters? Additionally, what backup systems are in place if regional transfer centers become inoperable? 

• The federal patient movement system involves separate entities. Control is primarily at airports/hubs and transfer centers, mostly managed by VA, DoD, Army, and DHA, each responsible for their area and capacity. While a national operations center is desired, current practice relies on just-in-time reporting of bed availability, making the immediate count of free beds unknown, but capacity can be determined upon activation. 

Has the National Disaster Medical System (NDMS) MOU been updated, and have there been efforts to recruit additional NDMS hospitals?

• We are actively seeking to expand our network of hospitals and have made hospital recruitment a top priority. Currently, we have Memorandums of Understanding (MOUs) with approximately 1700 hospitals, covering about half of all hospitals. Our goal is to reach every hospital. We do not require hospitals to reserve beds for us; we only inquire about their available capabilities when needed. In the event of a disaster, hospitals will receive compensation at 125% of the Medicaid rate for treating any uninsured individuals, with the NDMS and federal government guaranteeing payment.

Where might exercise planners find assistance for developing patient descriptions for exercise? 

• https://asprtracie.hhs.gov/technical-resources/7/exercise-program/1 

• Some scenarios that DOD Special Operations Medical teams use   https://prolongedfieldcare.org/2017/03/13/deploying-soon-click-here/   

• Medical Operations Coordination Centers (MOCCs) Resources Page https://asprtracie.hhs.gov/MOCC 

Are there specific grant opportunities available to individual hospitals/emergency departments to fund disaster training/drills?

• The main cooperative agreement is the Oxford agreement, which supports hospitals and NDMS providers within coalitions. ASPR is a small part of HHS, and I'm not aware of grants going directly to hospitals. 

• Disaster Available Supplies in Hospitals (DASH) Tool  https://asprtracie.hhs.gov/dash-tool 

• Topic Collection https://asprtracie.hhs.gov/technical-resources/96/blood-and-blood-products/0  

• Topic Collection https://asprtracie.hhs.gov/technical-resources/31/pediatric-children/0 

You mentioned the Strategic National Stockpile, who can contact the SNS? is it individual hospitals? local government? and how would someone contact the SNS to gain additional resources? 

• Requests are processed at the state level. We can address questions and prefer not to pass on any inaccurate information. We often receive SNS questions, which she forwards to the SNS Operations Team.

Recent intelligence has indicated a multi-phase attack on healthcare facilities. In light of this, are we considering moving the experienced physician closer to the entrance of the emergency department (ED) and possibly placing that physician "one wall back" for added security and protection? The ongoing conflict in Ukraine has emphasized the importance of this measure.

• Many healthcare facilities have yet to proactively incorporate mass casualty incident (MCI) planning. This should be a key consideration during initial planning. Given the unique nature of each MCI, both the staging and planning will necessarily differ.

• https://files.asprtracie.hhs.gov/documents/family-assistance-center-summary.pdf 

Any information on Alternative Care Facilities which might need to be quickly established?

• https://asprtracie.hhs.gov/HRROG

• Here is a link to our Exercise Program Topic Collection--there are some templates that might be helpful, but please reach out to us if you  need more. https://asprtracie.hhs.gov/technical-resources/7/exercise-program/1

• Search the ASPR TRACIE Resource Library and view tailored Topic Collections comprised of current healthcare system preparedness resources.

ASPR TRACIE is a tremendous and practical asset.  Aside from a sense of responsibility to the community - what motivators exist for private sector hospitals to plan for disasters?

• Several key factors motivate disaster preparedness: regulatory requirements from The Joint Commission and NDMS, a return on investment for private facilities (especially considering mass gathering attacks and natural disasters), and the financial and staffing benefits highlighted by TRACIE. Ultimately, preparedness saves money and helps retain staff. 

This invaluable resource appears critical. Is there an industry contingency plan to replicate it should funding be lost due to realignment projects such as DOGE?

• Great question in which I do not have an answer for, note that I am in critical resource, if anything does happen to ASPR TRACIE, we will ensure links that we have developed will still be on the website.

Thank you for the presentation. Acute care hospitals are mandated to have disaster preparedness and response plans through The Joint Commission and other bodies. Are there comparable initiatives, such as CMS payment incentives for specific treatments, to encourage disaster preparedness among urgent care facilities and other healthcare settings where patients might seek care independently?

• Currently, I don't have specific knowledge of HPB hospitals' activities. However, these hospitals are encouraging other entities to join healthcare coalitions. 

Do you know of a good cost benefit analysis that can be shared with private hospital leadership?

• Nursing and emergency management training has proven successful and is widely available. While an internal analysis is currently unavailable, I will check with ASPR TRACIE for relevant information.

• Emergency Preparedness Information Modules for Nurses Return on Investment (EPIMN ROI) Calculator (compliant PDF): The Emergency Preparedness Information Modules for Nurses Return on Investment (EPIMN ROI) Calculator is designed to assist healthcare systems in estimating the ROI of providing training based on EPIMN to their acute care nurses. The tool uses the default values described in the ROI framework for a representative hospital as inputs. The outputs include initial and subsequent year training costs, expected yearly gain, and ROI by year for 10 years. Users have the option to input alternate values based on their hospital or healthcare facility’s data to calculate results more representatives of their situation. Access the Excel version at: https://files.asprtracie.hhs.gov/documents/aspr-tracie-epimn-roi-calculator.xlsx. 

• Hospital Preparedness and Financial Benefits

• Author: ASPR TRACIE. Date Published: 2023. Annotation:  This ASPR TRACIE TA response includes resources related to hospital benefits resulting from preparedness, return on investment in healthcare preparedness, and additional resources related to the cost of healthcare preparedness. https://files.asprtracie.hhs.gov/documents/aspr-tracie-ta---hospital-preparedness-and-financial-benefits.pdf 

The presentation has been informative. I have a question regarding the potential of the National Emergency Medical Services Information System (NEMSIS) as a tracking tool in disaster situations for purposes such as patient location and proactive resource allocation. Our EMS and hospital providers often face challenges in utilizing traditional triage tags during multi-casualty incidents. Could the near real-time data extracted by NEMSIS from their standard Patient Care Reports (PCRs) be leveraged for disaster response at local, state, and federal leadership levels?

• The use of NEMSIS for tracking patients involves navigating individual state regulatory capacities and securing agreements, which presents a challenge due to varying state preferences. This approach, while a great idea with numerous tracking measures, is a work in progress due to the complexities of achieving multi-state consensus.

What are the primary obstacles preventing individual agencies from implementing prehospital blood administration? Is lack of funding the main reason?

• Many attribute challenges to funding limitations, while others haven't assessed community needs. The DoT summit gathers government and hospital representatives (like blood centers illustrating reduced waste and increased blood administration in Colorado Springs). This community-wide effort will explore varied approaches and future steps, leveraging a partnership with the National Center. A signed interagency agreement provides $30 million to advance blood transfusion initiatives nationally.

• Logistics and funding are key challenges. Logistically, ensuring proper blood typing and titration, maintaining chain of custody and administrative oversight, determining the blood supplier (local trauma center or blood bank), and keeping the blood cold are complex issues. Addressing these logistical demands consequently impacts funding.

Where will the PBT (prehospital blood transfusion) summit be held on 6/11/2025?  

• The Department of Transportation (DoT) will host a hybrid event with limited in-person attendance and many virtual speakers. An announcement with registration details and a tentative agenda will be sent to all EMS.gov subscribers.

Are there new technology needs for EMS prehospital blood transfusions that provider agencies would have to acquire before implementing such care? 

• Several agencies are leveraging technology to enhance program efficiency by analyzing historical call volume data. This analysis aims to pinpoint locations with the highest incidence of hemorrhaging among patients with the greatest need.

Is the Department of Transportation (DOT) examining the potential of using Unmanned Aircraft Systems (UAS) for delivering blood in rural areas, aiming to decrease or eliminate the necessity of transporting it in trucks?

• The Volpi Center is conducting a blood logistics study to determine the feasibility of using drones for blood delivery in remote and challenging environments. Phase 1 has been completed, and Phase 2 is planned.

How do you prepare for natural disasters (tornadoes, thunderstorms, etc.) when planning for 'tailgaters' in areas that have no indoor backups, especially when dealing with those that may have partaken in excessive libations?

• Law enforcement partnerships are crucial for managing fan activities outside events. Effective communication and enforcement by law enforcement are vital for fan safety in these situations. Handling such events largely depends on whether the property is private or public. Annual risk assessments are necessary to prepare for these occurrences.

How is Artificial Intelligence (AI) being used for event security?

• Facial recognition technology is being implemented in credentialing, enabling ticketless and cashless entry and purchases at events. AI-powered magnetometers are also used for efficient security screening at event entrances.

Do you think that gaming can be useful in encouraging interagency/inter-organization collaboration?

• Yes, absolutely. There is a slide referring to this in the presentation. Partnerships and interagency collaboration is a huge challenge in disaster preparedness and response. Gaming is a great way to encourage collaboration and communication.

Do you have a mechanism to input real time (e.g., resource availability, hospital bed state) information to a simulation.  For example, the UK's National Health Service (NHS) uses the Swedish Emergo simulation. Very useful to contextualize the game to a real life situation?

• Will have to take this question and feedback to game designers at CAPTRS.

Have you been able to work with Artificial Reality/Virtual Reality/XR in gaming? This would seem a modern approach to training that could involve some of these same attributes as gaming. If so, thoughts?

• Yes, a colleague in England is using immersive virtual reality to work on preparedness in response to bombings.

• Can you ask what the most challenging game has been to work on? Can't speak for design team but games that have to take geopolitical politics and other sensitive considerations are difficult.

Additional gaming / stimulation resources:

• This simulation activity is special pathogen related but a fun one individually or as a group: https://www.ready-initiative.org/outbreak-ready-digital-simulations/outbreak-ready-original-simulation/ 

• CDC also developed a game series, with one coming out to teach Incident Command principles https://www.cdc.gov/readiness/php/testgame/index.html

• Rescue-D for EMS, an online role play simulation for first responders to learn about appropriate 1:1 interactions with people with disabilities https://www.psglearning.com/catalog/productdetails/9781284128833  (this is a commercial game, but low cost)

•  For MIMMS and the Hospital version get in touch with the Advanced Life Support Group (UK) at: https://www.alsg.org/  

• Integrity games used: https://www.undp.org/moldova/press-releases/4integrity-anticorruption-game-youth-launched-undp-and-national-anticorruption-centre  

Has non-clinician hospital staff been trained using these types of programs to enhance their ability to respond to a Mass Casualty Incident (MCI)?

• Yes, there are health systems that are starting to do this, such as Mt. Sinai in New York. 

What has Stop the Bleed's strategy been to try to reach and then train large numbers of people? 

• It's important to emphasize the idea of "whatever you're giving to give, we'll take." We must continue to ensure that we meet people where they're at. It's also important to break down barriers to participation such as cost. 

How do you monitor and evaluate outcomes and impact of the training? Outputs and Key Performance Indicators (KPIs) are easy to monitor but outcomes are more elusive and impact is longitudinal. 

• It's very difficult to evaluate when training the general public. We can count how many people we train and summarize their background, but what's really important is to work with care providers to ensure that information in the training is correct. We have to try to understand what care providers are seeing in terms of proper tourniquet use to ensure we adapt.

Other than blood products, what other skills from military medics can be applied to civilian EMS for mass casualty attacks on civilian populations? 

• Surgeons have advanced catheters, blood products, etc. and we also are investing a lot in military medics in prolonged care. Blurring the lines between clinical and civilian support is important. We encourage efforts like STOP THE BLEED® and other bystander trainings that will allow us to be better prepared.

What is the role of U.S. Northern Command (NORTHCOM)  for large civilian mass casualty events (I'm thinking at the scale of 9/11)? 

• NORTHCOM's role is situation-dependent. In a defensive scenario, its priority is presidential security, including analyzing defense and attack strategies. Additionally, NORTHCOM acts as a liaison, where feasible and appropriate, between the Department of Defense and civilian entities.

Are walking human blood banks being used to transport blood into Role 1 facilities?

• Combatant commands are establishing registries and preparing walking blood banks for the next combat scenario. This includes examining blood banks and blood products in other countries, even those from non-American donors.

Thoughts on a National Emergency Patient transfer system for inter hospital and field transfers?

• It would be great. Many organizations have similar concepts on the table, but it's difficult to communicate ideas in a way to coordinate all the concepts and organizations involved. There are a lot of plans on different levels (regional, state, federal, etc.) that are difficult to combine due to system incompatibilities among other considerations. We do need this though.