Ebola Virus Disease Coordination and Transportation Plan City of Chicago & States of Illinois, Indiana, Michigan, Minnesota, Ohio and Wisconsin December 2016

HHS Region V: Ebola Virus Disease Coordination and Transportation Plan City of Chicago & States of Illinois, Indiana, Michigan, Minnesota, Ohio and Wisconsin December 2016

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Table of Contents

HHS Region V: Ebola Virus Disease Coordination and Transportation Plan ...... i Table of Contents ...... ii Promulgation Statement ...... 1 Approval and Implementation ...... 2 Signature Page ...... 3 Record of Changes ...... 4 Record of Distribution ...... 6 1. Purpose, Scope, Situation and Assumptions ...... 7 1.1 Purpose ...... 7 1.2 Scope ...... 7 1.3 Situation Overview ...... 7 1.3.1 Description of the Disease ...... 7 1.3.2 Transmission ...... 7 1.3.3 Description of HHS Region V ...... 8 1.4 Planning Assumptions ...... 8 1.4.1 Patient Diagnosis and Preparation for Transport ...... 8 1.4.2 Patient Transportation Readiness ...... 8 1.4.3 Region V RTC Readiness ...... 9 2. Organization and Anticipated Responsibilities ...... 10 2.1 Organization ...... 10 2.2 Anticipated Responsibilities ...... 10 2.2.1 Federal Level — U.S Department of Health and Human Services ...... 10 2.2.2 Regional Level ...... 11 2.2.3 Jurisdictional (City of Chicago or State) Level ...... 12 2.2.4 Local or Tribal Level ...... 12 3. Direction, Control, and Coordination ...... 14 3.1 Authority to Implement Plan ...... 14 3.1.1 Transfer of Patient to Region V RTC ...... 14 3.1.2 Transfer of Patient to Region V Ebola Treatment Center (ETC) other than the Region V RTC Across State Lines ...... 14 3.1.3 Transfer of Patient to an HHS RTC other than Region V...... 14 3.2 Communication and Coordination...... 14 3.2.1 Federal Level ...... 14 3.2.2 Originating Jurisdictional Health Department ...... 14 3.2.3 Receiving Jurisdictional Health Department ...... 15 3.3 Initial Notification and Patient Placement ...... 15 3.3.1 Initial Notification ...... 15

3.3.2 Patient Placement (Region V) ...... 16 3.3.3 Acceptance of Patient at Region V RTC ...... 16 3.3.4 Patient Placement (Other HHS Region) ...... 16 3.4 Air Transport to the Region V RTC ...... 16 3.4.1 Situation ...... 16 3.4.2 Assumptions ...... 16 3.4.3 Concept of Operations...... 17 3.5 Ground Transport to the Regional Ebola Treatment Center ...... 19 3.5.1 Situation ...... 19 3.5.2 Assumptions ...... 19 3.5.3 Concept of Operations...... 20 3.5.4 Patient Transfer Points ...... 20 3.6 Decontamination and Waste Management ...... 21 3.6.1 Purpose ...... 21 3.6.2 Situation ...... 21 3.6.3 Assumptions ...... 22 3.6.4 Concept of Operations...... 22 3.7 Provider Safety ...... 23 3.7.1 Purpose ...... 23 3.7.2 Guidance ...... 23 3.8 Mortuary Affairs ...... 24 3.8.1 Purpose ...... 24 3.8.2 Situation ...... 24 3.8.3 Assumptions ...... 24 3.8.4 Concept of Operations...... 24 3.9 Medical and Legal Considerations ...... 25 3.9.1 Transport Considerations ...... 25 3.9.2 Medical Treatment Considerations ...... 25 4. Administration and Finance ...... 26 4.1 Administration ...... 26 4.2 Finance ...... 26 4.2.1 Reimbursement Information for Treatment and Transport of EVD Patient ...... 26 4.2.2 Ebola Treatment Reimbursement Program for U.S. Hospitals ...... 27 5. Training and Exercise ...... 28 5.1 Training ...... 28 5.1.1 Training Plan Development ...... 28 5.1.2 Training Plan Implementation...... 28

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5.2 Exercise ...... 28 5.2.1 Exercise Plan Development ...... 28 5.2.2 Exercise Plan Implementation ...... 28 5.2.3 Select HPP Ebola Grant Performance Measures for Regional Transport ...... 29 6. Plan Development, Maintenance, and Review ...... 30 6.1 Development ...... 30 6.1.1 Lead Agencies ...... 30 6.1.2 Supporting Agencies ...... 30 6.2 Maintenance ...... 30 6.2.1 Requirements ...... 30 6.3 Review and Update ...... 30 6.3.1 Review ...... 30 6.3.2 Updates and Changes ...... 31 7. Authorities and References ...... 32 7.1 Legal Authority ...... 32 7.1.1 Federal ...... 32 7.1.2 Jurisdiction ...... 32 7.2 References ...... 32 7.2.1 Federal ...... 32 7.2.2 Jurisdiction ...... 32 Appendices ...... 33 Appendix A: Abbreviations and Acronyms ...... 33 Appendix B: Jurisdiction Capabilities ...... 36 A. City of Chicago (as of December 1, 2016) ...... 37 B. Illinois (as of December 1, 2016) ...... 40 C. Indiana (as of December 1, 2016) ...... 43 D. Michigan (as of December 1, 2016) ...... 45 E. Minnesota (as of December 1, 2016) ...... 49 F. Ohio (as of December 1, 2016)...... 53 G. Wisconsin (as of December 1, 2016) ...... 56 Appendix C: Initial Notification Flowchart ...... 59 Appendix D: Ebola Patient Decision Algorithm ...... 60 Appendix E: Inter-Regional Transfer ...... 61 Appendix F: List of Region V Ground Transport Designated Patient Transfer Points ...... 62 Appendix G: Map of Region V Ground Transport Patient Transfer Points for Ebola ...... 64 Appendix H: Definition of Terms ...... 65 Appendix I: Notification Checklist with Important Phone Numbers ...... 69

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Promulgation Statement

ON BEHALF of HHS REGION V City of Chicago and States of Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin HHS Region V Ebola Virus Disease Coordination and Transportation Plan

PROMULGATION High consequence infectious diseases (HCIDs), such as Ebola virus disease (EVD), threaten the public and the stability of the health care system. It is one of the many responsibilities of government to provide for the well-being of its citizens. The National Planning Frameworks describes how the entire community—local, state, and federal—work together to meet the National Preparedness Goal: “A secure and resilient nation with the capabilities required across the whole community to prevent, protect against, mitigate, respond to, and recover from the threats and hazards that pose the greatest risk.”1 The HHS Region V Ebola Virus Disease Coordination and Transportation Plan—hereinafter referred to as “the Plan” or “this Plan”—provides the necessary framework for the safe transport of highly suspected or confirmed patients with EVD or other HCID to the designated Region V Ebola or Other Special Pathogens Treatment Center at the University of Minnesota Medical Center-West Bank Campus in Minneapolis, Minnesota (Region V RTC). The Plan addresses roles, responsibilities, and the authority of local, state, and federal entities to address safe transport and medical treatment of such patients in the City of Chicago and states of Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin. The Plan is consistent with each jurisdiction’s Concept of Operations (ConOps) for Ebola within HHS Region V. It will be routinely reviewed and modified as deemed appropriate by all members. Therefore, in recognition of the public health and medical responsibilities of the governments of each member of HHS Region V and with the authority vested in the City and State Health Officials of HHS Region V, we hereby promulgate this HHS Region V Ebola Virus Disease Coordination and Transportation Plan.

Julie Morita, MD Edward Ehlinger, MD, MSPH City Health Official, City of Chicago State Health Official, State of Minnesota

Nirav D. Shah, MD, JD Richard Hodges, MPA State Health Official, State of Illinois State Health Official, State of Ohio

Jerome Adams, MD, MPH Karen McKeown, RN, MSN State Health Official, State of Indiana State Health Official, State of Wisconsin

Sue Moran, MPH State Health Official, State of Michigan

1 “National Preparedness Goal,” Federal Emergency Management Agency, updated July 5, 2016, accessed June 6, 2016, http://www.fema.gov/national-preparedness-goal.

Approval and Implementation

The management authority for actions during an EVD response is done through the execution of the affected HHS Region V member’s Ebola ConOps. The implementation of this plan is executed by the affected HHS Region V member’s Authorized Public Health and Health Care Agency in conjunction with the Minnesota Department of Health. This plan outlines the direction, control, and coordination protocols required for implementation. The Plan delegates the HHS Region V member’s Health Officials’ authority to specific individuals in the event he or she is unavailable. The designated deputy for chain of succession in a major infectious disease incident is as follows: Allison Arwady, MD, MPH Cheryl Petersen-Kroeber Chief Medical Officer, Director, Emergency Preparedness and Response, Chicago Department of Public Health Minnesota Department of Health

Don Kauerauf Mary DiOrio, MD, MPH Assistant Director, Medical Director, Illinois Department of Public Health Ohio Department of Health

Lee Christenson William L. Oemichen Director, Public Health Preparedness and Emergency Director, Office of Preparedness and Emergency Response, Health Care, Indiana State Department of Health Wisconsin Department of Health Services

Eden Wells, MD, MPH, FACPM Chief Medical Executive, Michigan Department of Health and Human Services

Signature Page

This document establishes an HHS Region V Ebola Virus Disease Coordination and Transportation Plan. The signatures below indicate adoption of the Plan. Approved by:

Julie Morita, MD, Commissioner, Chicago Department of Public Health (Date)

Nirav D. Shah, MD, JD, Director, Illinois Department of Public Health (Date)

Jerome Adams, MD, MPH, Commissioner, Indiana State Department of Health (Date)

Sue Moran, MPH, State Health Official, Michigan Department of Health and Human Services (Date)

Ed Ehlinger, MD, MSPH, Commissioner, Minnesota Department of Health (Date)

Richard Hodges, MPA, Director, Ohio Department of Health (Date)

Karen McKeown, RN, MSN, State Health Officer, Wisconsin Department of Health Services (Date)

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Record of Changes

Change # Date Part Affected Date Posted Who Posted

Record of Distribution

Plan # Office/Department Representative Signature

1. Purpose, Scope, Situation and Assumptions

1.1 Purpose Science and experience has proven the care of individuals infected with EVD or other HCID, is clinically complex and requires highly skilled professionals with access to technologically advanced care. This led United States Government experts and stakeholder groups to suggest the care of these patients should be concentrated in a small number of facilities. Therefore, each national region determined by the U.S. Department of Health and Human Services (HHS), has established a Regional Treatment Center (RTC) for EVD and Other Special Pathogens to treat these types of diseases. This HHS Region V Ebola Virus Disease Coordination and Transportation Plan (“the Plan” or “this Plan”) provides the necessary framework for the safe transport of highly suspected or confirmed patients with EVD or other HCID to the designated RTC located at the University of Minnesota Medical Center-West Bank Campus (UMMC-West Bank) in Minneapolis, Minnesota (HHS Region V RTC).

1.2 Scope This Plan applies to the signatory departments and agencies within the geographic boundaries of HHS Region V. This includes: the City of Chicago and the states of Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin. The HHS Region V RTC is UMMC-West Bank in Minneapolis, Minnesota.

1.3 Situation Overview The 2014-2016 EVD outbreak in West Africa increased the possibility of patients with EVD traveling from the affected countries to the United States. The Centers for Disease Control and Prevention (CDC) and partners worked to contain this epidemic at its source. Sierra Leone, Liberia, and Guinea were hardest hit; there were also cases reported in Senegal, Nigeria, Italy, Spain, Mali, the United Kingdom, and the United States.2 1.3.1 Description of the Disease EVD is a disease caused by the Ebola virus. The incubation period from exposure to appearance of signs and symptoms ranges from 2 to 21 days (most commonly 8-10 days). Symptoms may include fever, headache, joint and muscle aches, weakness, diarrhea, vomiting, stomach pain, and abnormal bleeding. 1.3.2 Transmission Ebola virus is believed to have a natural reservoir in animals and is transmitted to humans through animal contact. Once human infection occurs, people are not contagious until they develop symptoms. Transmission person-to-person is extremely low unless direct contact with body fluids or contaminated objects (such as needles) of a symptomatic person or one who has died from EVD occurs. Recent case reports indicate the Ebola virus could remain in some body fluids (e.g., semen) of EVD survivors longer than previously suspected.

2 “2014 Ebola Outbreak in West Africa – Case Counts,” Center for Disease Control and Prevention, updated April 13, 2016, accessed April 14, 2016, http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-counts.html. 7

Therefore, transmission from asymptomatic survivors is possible. Those at highest risk for EVD include health care workers and other people with direct contact with infected, symptomatic people’s body fluids or a corpse infected with EVD. Effective isolation of patients and appropriate infection control measures can help contain potential spread of the disease. 1.3.3 Description of HHS Region V HHS Region V covers seven jurisdictions. They are the City of Chicago and six states— Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin. For the purposes of this Plan, “jurisdiction” refers to the City of Chicago or one of the six states within the geographic boundaries of HHS Region V. For details and a description of each jurisdiction’s EVD response capabilities, as they pertain to this plan, please reference Appendix B: Description of Jurisdictions’ Capabilities.

1.4 Planning Assumptions Planning assumptions include, but are not limited to, the following: 1.4.1 Patient Diagnosis and Preparation for Transport  The Sending Hospital serves as a jurisdictional Assessment Hospital (AH) or Ebola Treatment Center (ETC).  Patient diagnosis is confirmed EVD or another HCID and the patient’s attending physician and/or clinical team has determined that air or ground transport to the Region V RTC is appropriate.  Transfer to the Region V RTC should be ruled out before discussing transport to a RTC outside of Region V. 1.4.2 Patient Transportation Readiness  Fixed-wing air ambulance transport is the preferred mode of transportation for distances over 200 miles from the RTC.3  Phoenix Air Group, Inc. (PAG), the federally contracted fixed-wing air ambulance provider, is available and will respond to a transport request within 12 hours of notification.  If PAG is not available, ground transportation may be necessary.  Ground transport is the preferred mode of transportation for distances under 200 miles from the RTC.  EMS agencies involved in the transport of a confirmed EVD patient can transport the patient within four hours of notification.4

3 The recommended 200 mile radius may be extended should PAG response be delayed, and will be determined on a case by case basis. 4“Measurement Implementation Guidance: Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities CFDA #93.817, Performance Measure 1,” U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response, 2015. 8

1.4.3 Region V RTC Readiness  The Region V RTC is ready to accept a patient within eight hours of notification.5  The Region V RTC has the capacity and capability to treat two patients (adult or pediatric) at one time.  The Region V RTC has dedicated treatment and PPE donning and doffing areas, skilled and trained staff, appropriate equipment and appropriate infection control procedures.

5 Ibid. 9

2. Organization and Anticipated Responsibilities

2.1 Organization Due to its highly infectious nature, a confirmed EVD patient must be treated as an emergency. Each member of HHS Region V operates under the National Response Framework (NRF) when responding to a disaster or emergency. Under NRF guidance, specific roles and responsibilities required of stakeholders should be clearly delineated prior to such event. The anticipated responses of an EVD patient response are listed below.

2.2 Anticipated Responsibilities

2.2.1 Federal Level — U.S Department of Health and Human Services  Assistant Secretary for Preparedness and Response (ASPR) and HHS Secretary’s Operation Center o Requests air transport from the Department of State (DOS). o Facilitates communication among all agencies and individuals about incoming patients. o Keeps all involved in patient transport informed during the process. o Assists with patient return to home state if necessary.  CDC o CDC Emergency Response Teams (CERT), made up of experts in epidemiology, infection control, laboratory, and communications are on stand-by, and ready to deploy to any hospital in the United States with a probable case. o Will arrange a clinical call amongst subject matter experts (SMEs), the hospital transferring the confirmed patient, and the Region V RTC accepting the patient to discuss patient care.  National Ebola Training and Education Center (NETEC) o Provides guidance and conducts annual site visits to the Region V RTC during the five-year Hospital Preparedness Program (HPP) Ebola grant period to ensure the Region V RTC maintains its capabilities and readiness to respond to EVD. o Continues to provide training to physicians and nurses who staff the Region V RTC. o In case of a confirmed EVD case, provides clinical and technical guidance to any hospital and EMS involved in patient care within the U.S. and Territories. o Continues to provide technical assistance to all U.S. and Territory hospitals specific to other new HCIDs upon request and as available resources allow.

 PAG o Properly transports via fixed-wing aircraft a patient with confirmed or highly suspected EVD from originating jurisdiction to a designated airport near the Region V RTC. o Maintains air ambulance crew readiness with adequate training. o Responds to request within 12 hours of notification of need to transport. 2.2.2 Regional Level  Minnesota Department of Health o Develops and oversees the implementation and exercise of this Plan through the Great Lakes Health Care Preparedness Partnership (GLHP), an interstate coordinating body within the geographic boundaries of HHS Region V. o Receives requests to transport EVD patients to the Region V RTC from other HHS Region V jurisdiction health departments. o Communicates with the Region V RTC to determine bed and staff availability.  Region V RTC: University of Minnesota Medical Center-West Bank6 o Serves as the HHS regional treatment hospital of confirmed EVD patients. o Ready to accept patients from HHS Region V within eight hours of notification. o Maintains capability and has capacity to treat at least two EVD or other HCID patients (adult or pediatric) at one time. o Maintains respiratory isolations, infectious disease capacity or negative pressure rooms for at least ten patients, preferably, within the same unit. o If necessary, will accept patients medically evacuated from Ebola- affected countries or other HHS regions. o Maintains a heightened state of readiness for at least the five-year project period by conducting quarterly staff trainings and exercises. o Receives and participates in training, peer review, and an assessment of readiness from NETEC to ensure adequate preparedness and trained clinical staff knowledgeable in treating patients with EVD. o Cares for EVD patients without disrupting overall hospital operations. o Maintains the capability to handle Ebola-contaminated (Category A) or other highly-contaminated infectious waste. o Integrates behavioral health considerations for patients and staff, as well as the provision of culturally and linguistically appropriate services, into medical and safety procedures. o Participates in clinical research, clinical trials, and experimental protocols, if appropriate. o Works with human resources departments, as well as relevant employee unions, to develop policies and procedures to ensure health care worker readiness and safety associated with caring for an EVD patient.

6 “Funding Opportunity Announcement: Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities CFDA #93.817,” U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response, 2015.

2.2.3 Jurisdictional (City of Chicago or State) Level  Department of Health o Coordinates and provides situational awareness to: . HHS, including ASPR and CDC . HHS Region V health departments . City/State pre-identified EMS agency(s) . City/State Emergency Management Agency . Patient Transfer Points (PTPs) . Waste management . Mortuary affairs . Other resources as specified. o Implements their jurisdiction’s ConOps for EVD.  State Emergency Management Agency o Conducts response operations in accordance with National Incident Management System. o Coordinates resource requests during an incident through the management of an emergency operations center, if applicable. o Facilitates local emergency management assistance as required. o Communicates and coordinates with Law Enforcement agencies as required by jurisdiction practices.  Health Care Coalitions (HCCs) o Provides situational awareness to coalition members when appropriate and where applicable. o In some HHS Region V jurisdictions, the HCCs may play a coordinating role. 2.2.4 Local or Tribal Level  Health Departments o Coordinates with the appropriate jurisdictional health department(s).  Sending Hospital (AH or ETC) o Works in concert with appropriate state and federal entities to provide adequate testing for diagnosis prior to the transfer of patient to Region V RTC. o Provides clinical updates to EMS, PAG (if in use), and Region V RTC clinical staff. o Maintains capability to handle and dispose of Category A waste. o Provides space and disinfectant for EMS to perform gross decontamination of ambulance(s) used in transport, if needed. o Coordinates transport with appropriate EMS agency.  EMS o Maintains capability to transport a patient with EVD or HCID through regularly scheduled drills, education, and training. o Provides care to patient during transport within scope of practice and local medical direction. o Manages waste from patient transport per protocols.

 Emergency Management Agency o Facilitates communication with the State Emergency Management Agency. o Facilitates local EMA response if required.  Law Enforcement Agencies o Maintains law and order. o Controls traffic during transport as needed. o Coordinates with local airport security as appropriate.

3. Direction, Control, and Coordination

3.1 Authority to Implement Plan

3.1.1 Transfer of Patient to Region V RTC The authority to implement this plan rests with the affected jurisdictions’ authorized public health coordinating agency in concert with the MDH. This process will include coordination with the HHS Region V Regional Emergency Coordinators (RECs). 3.1.2 Transfer of Patient to Region V Ebola Treatment Center (ETC) other than the Region V RTC Across State Lines If the RTC is unable to accept a patient for any reason, the authority to transfer to another ETC across state lines within HHS Region V rests with the affected jurisdictions’ authorized public health coordinating agency in concert with the appropriate receiving jurisdictions’ public health authority. This process will include coordination with HHS Region V RECs and members. 3.1.3 Transfer of Patient to an HHS RTC other than Region V The authority to transfer to another HHS RTC outside Region V rests with the affected jurisdictions’ authorized public health coordinating agency in concert with the receiving jurisdictions’ public health authority. This process will include coordination with the Region V HHS REC and accepting Region’s REC. The procedure for this type of transfer is beyond the scope of this Plan and will be evaluated and coordinated on a case by case basis.

3.2 Communication and Coordination

3.2.1 Federal Level  HHS ASPR RECs should communicate operational needs, situational awareness, and operational tasks including the need for air transport from DOS, with the ASPR Secretary’s Operations Center (SOC), MDH, and the jurisdiction where the patient is located and other stakeholders as needed.  The SOC and ASPR Emergency Management Group (EMG) should communicate operational needs with the RECs to support the overall patient movement and management operation as needed.  RECs should coordinate communication with all jurisdictions involved directly with the transport of a patient, particularly if ground transport is necessary or preferable over air transport. 3.2.2 Originating Jurisdictional Health Department  Should notify MDH within 30 minutes of confirmation that a patient is diagnosed with EVD and requires transport to the Region V RTC.7  Notifies the HHS Region V REC of confirmed positive Ebola case and request air transport if appropriate.  Communicates situational awareness with HHS Region V.

7 “Measurement Implementation Guidance: Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities CFDA #93.817, Performance Measure 19,” U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response, 2015. 14

3.2.3 Receiving Jurisdictional Health Department  Communicates situational awareness with HHS Region V Health Departments, RECs and HPP Project Officer.

3.3 Initial Notification and Patient Placement

3.3.1 Initial Notification Once there is a confirmed EVD or other HCID patient located in HHS Region V, certain entities must take responsibility for notifying key stakeholders in activating this plan. For more information please reference Appendix C: Initial Notification Flowchart and Appendix I: Notification Checklist with Important Phone Numbers.  Lab performing positive test result in conjunction with confirmatory lab should notify: o Hospital where the patient is located (Sending Hospital) o State laboratory and/or health department (if applicable) o CDC Laboratory  Sending Hospital should notify: o Local and State public health authority o May be in collaboration with the HCC in some jurisdictions  Affected jurisdiction’s health department should notify: o Minnesota Department of Health (within 30 minutes)8 o HHS Region V REC9 o HHS Region V HPP Project Officer o Airport A10 o CDC Quarantine Station (if appropriate)11  Minnesota Department of Health should notify: o RTC: University of Minnesota Medical Center-West Bank Campus o Metropolitan Airports Commission/Airport B12  HHS Region V REC should notify: o HHS Secretary’s Operation Center (SOC)  HHS SOC should notify: o CDC Emergency Operations Center (EOC) o Federal Department of State (DOS)  HHS Region V HPP Project Officer should notify: o HHS Region V 24/7 health department contact per Appendix B of this plan  Federal Department of State should notify: o Fixed-wing air ambulance, PAG  Region V RTC should notify: o “Ebola/HCID Ready” Ambulance Service to pick patient up at Airport B

8 Ibid. 9 If unable to repeatedly reach the HHS Region V REC, the affected jurisdiction’s health department should contact the HHS SOC directly at (202) 619-7800. 10 Airport A is the designated airport in which the fixed-wing air ambulance will pick-up the patient. 11 Michigan and Ohio report to Detroit, MI CDC Quarantine Station; Indiana, Illinois, City of Chicago, and Wisconsin report to Chicago, IL CDC Quarantine Station; Minnesota reports to Minneapolis, MN CDC Quarantine Station. 12 Airport B is the designated destination airport of the fixed-wing air ambulance with the patient. 15

3.3.2 Patient Placement (Region V) MDH will contact the Region V RTC to determine bed availability on the Ebola and Other Special Pathogens Unit. If available, MDH will coordinate a conference call between the two health care facilities for patient status, clinical updates, and any other information needed at this time. If the Region V RTC is unavailable for any reason, MDH will notify the Region V REC, HPP Project Officer, and affected jurisdiction’s health department so alternate plans can be made in accordance with the Ebola Patient Decision Algorithm in the HPP Ebola Preparedness and Response Activities Funding Opportunity Announcement (FOA).13 (See Appendix D: Ebola Patient Decision Algorithm). 3.3.3 Acceptance of Patient at Region V RTC MDH will coordinate communication between the Region V RTC and the Sending Hospital so the Region V RTC clinical staff will have patient status information. The Region V RTC will confirm acceptance of the patient and will complete a patient report with the Sending Hospital and originating jurisdiction’s Health Department. Once this is completed, the Region V RTC will notify MDH; MDH will proceed with implementation of this Plan with the REC. 3.3.4 Patient Placement (Other HHS Region) The affected jurisdiction’s health department will work with the REC and HHS/CDC Leadership to place the patient at a RTC outside of Region V if necessary. The affected jurisdiction will coordinate with the accepting region to implement their plan.

3.4 Air Transport to the Region V RTC

3.4.1 Situation For distances over 200 miles from the Region V RTC, fixed-wing air ambulance is the preferred method of transport for patients due to their contagious status. Air transport should be ruled out as an option prior to discussing ground transport. Coordinating a fixed- wing air ambulance transport involves local, state, and federal entities. Through the U.S. Department of State (DOS), PAG, based in Cartersville, Georgia is the sole provider of this transport. 3.4.2 Assumptions  Patient death is not imminent.  PAG maintains two Gulfstream G-III aircraft with Aeromedical Biological Containment System (ABCS) installed.  PAG staff will accept and provide medical care to the patient during transport.  PAG will follow their company policies and procedures regarding waste management and decontamination in accordance with state and federal regulations.  Local EMS will follow their company policies and procedures regarding waste management and decontamination in accordance with state and federal regulations.

13 “Funding Opportunity Announcement: Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities CFDA #93.817,” U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response, 2015, p 34-35. 16

3.4.3 Concept of Operations There are three legs of the journey when completing a fixed-wing air ambulance transport of an EVD patient described in this plan:  Leg 1: Sending Hospital to Airport A  Leg 2: Airport A to Airport B  Leg 3: Airport B to Regional Treatment Center (Receiving Hospital)

The request for the PAG fixed-wing air ambulance must be made through the federal Department of State. To request this service, partners complete the following:  The sending or affected jurisdiction’s health department contacts the designated HHS Region V REC to request air transport and o Provides location of Airport A. o Provides a point of contact for coordination of transport times. o Provides general information about patient condition (specifically if patient is adult or pediatric and patient symptoms). The HHS Region V REC, in coordination with other federal officials and entities, including the HHS SOC will:  Liaise with and coordinate the multiple federal agencies engaged in the transport.  Request air transport services from Department of State (DOS).  Provide interstate and interagency communications for the need for transfer of an EVD or HCID patient.  Assist with air and ground transportation logistics as needed.  Facilitate communication among agencies and individuals about incoming patients.  Facilitate logistics when appropriate and ensures logistics are considered (e.g., law enforcement escort).  Facilitate conference calls with parties involved when arrangements are complete and prior to arrival.  Keep all parties informed during transport and until patient reaches final destination.  Assist with patient return to home state as necessary.

The federal government assumes financial responsibility either directly or through reimbursement for payment of an air transport of an EVD patient to the Region V RTC.14 Leg 1: Sending Hospital to Airport A It is the responsibility of the sending hospital with their local/state health department and EMS agencies, to coordinate appropriate transport of the patient from the sending hospital to Airport A in accordance with their jurisdictional ConOps. Each designated airport is listed within each jurisdiction’s plan and can be found in Appendix B: Jurisdiction Capabilities. Airport A is the designated airport in which the fixed-wing air ambulance will pick-up the patient. The state and/or local jurisdictions are responsible for designating airports to serve in this capacity, and establishing an agreement to use the airport in a real incident. The airport must meet the following requirements for PAG’s Gulf Stream G-III aircraft with ABCS to land and take off: 1. Have a 5,100 feet15 accelerate-stop distance available (ASDA) runway with a maximum ramp weight of 70,200 pounds. 2. Have a direct route outdoors (or for inclement weather, space within a hanger or other structure) for the ambulance transporting the patient from the sending hospital directly to the fixed-wing air ambulance. 3. Should be secure, with limited access and gated. Local crews transporting the patient to the airport should arrive prior to the air ambulance landing. The crew should remain in PPE until patient transfer and handoff to the PAG medical staff is completed. PAG medical staff will evaluate the patient and have the right to refuse transport if they believe patient death is imminent or the patient will not survive the flight. Local EMS crews should follow doffing, decontamination, and waste procedures per their jurisdictional ConOps in accordance with CDC guidance and their standard operating procedures (SOPs). Leg 2: Airport A to Airport B The confirmed EVD/HCID patient will be in the required and appropriate PPE prior to boarding the plane and isolation standards will be maintained during the entire length of flight per PAG company policies.16 Airport B is the designated airport where the fixed-wing air ambulance will land. Ideally, if the patient is being admitted to the Region V RTC (UMMC-West Bank), the air ambulance will land at Saint Paul Downtown Airport (Holman Field) (STP) for security reasons.17 However, if need be, Minneapolis-St. Paul International Airport and Rochester International Airport have runways of acceptable ASDA length for the fixed- wing ambulance to take off and land.18

14 H.R.83, Consolidate and Further Continuing Appropriations Act, 2015 https://www.congress.gov/113/plaws/publ235/PLAW-113publ235.pdf 15 Phoenix Air Groups, Inc. Worldwide Aircraft Services. PowerPoint. 16 Ibid. 17 “Airports: St. Paul Downtown,” Metropolitan Airports Commission (MAC), accessed May 2, 2016, https://www.metroairports.org/General-Aviation/Airports/St-Paul.aspx 18 “FAA Airport Diagrams,” Federal Aviation Administration (FAA), accessed March 22, 2016, http://www.faa.gov/airports/runway_safety/diagrams/

Leg 3: Airport B to the Region V RTC19 Transfers of this nature are considered a scheduled transfer, therefore an ambulance from HealthEast or another ambulance service properly equipped and trained to handle EVD/HCID patients will arrange to meet PAG at the airport and directly transport the patient to the Region V RTC. Upon arrival at the Region V RTC, the ambulance will report to the designated bay or unloading area for EVD/HCID patients. There, hospital staff will meet the ambulance crew for patient handoff. Hospital staff will then follow the Region V RTC’s pre-designated procedures to transfer the patient to the Special Pathogens Unit. EMS will perform a gross decontamination of the ambulance and doff in designated areas at the Region V RTC. In the event the Region V RTC is unable to accept a confirmed patient for any reason, under consultation from MDH and HHS/ASPR and CDC these plans will be modified to transport patient to either another ETC within Region V or a RTC in a different HHS Region. All stakeholders (GLHP, ASPR, CDC, PAG, sending and receiving hospitals) will be a part of modifying the plan.

3.5 Ground Transport to the Regional Ebola Treatment Center

3.5.1 Situation Patients located within 200 miles of the RTC will be transported by ground. However, if a patient is over 200 miles from the RTC and PAG is unavailable for a variety of reasons— weather, aircraft, and crew availability—a contingency ground transport plan must be in place. Regional ground transport will be based on each jurisdiction’s respective ConOps. Pre-identified EMS agencies will be used within each jurisdiction with pre-identified patient transfer points (PTPs) located at ETC or AH hospitals spread throughout HHS Region V (See section 3.5.4 for more detail). 3.5.2 Assumptions  Transfer of patient to the Region V RTC is recommended by the clinical team treating the patient at the AH or ETC in concert with local, state, regional, and federal public health authorities.  The patient is located within 200 miles of the RTC or PAG will be unavailable for air transport in a reasonable timeframe.20  EMS personnel can only comfortably be in full PPE for 3 to 3 ½ hours at a time, however situation(s) may arise that will lengthen this.  PTPs will be pre-identified jurisdiction AHs or ETCs.  Each leg of the transport will be discussed and a detailed strategy agreed upon prior to initiation of ground transport. Strategy must address, but is not limited to the following details:

19 “Interfacility Transport Guidance Example: Standard Operating Procedure (SOP) for Air-to-Ground Patient Handoff,” CDC, accessed April 25, 2016, http://www.cdc.gov/vhf/ebola/healthcare-us/emergency-services/air- ground-patient-handoff.html 20 Reasonable timeframe may vary depending on the clinical status of the patient and will be determined on a case- by-case basis. 19

o Route a. Patient Transfer Points (PTPs) b. EMS agencies and their leg of journey o Communications while in route o Contingencies 3.5.3 Concept of Operations Regional transportation decisions will be made between sending and receiving health departments and hospitals in accordance with jurisdictional ConOps, HHS and CDC, and the Ebola Patient Decision Algorithm in the HPP Ebola Preparedness and Response Activities FOA.21 PTPs will be utilized to change EMS personnel and if necessary vehicles. In the event a transfer of this nature overwhelms the local or state government, a request to activate the State’s National Guard may be made by the Governor. When requested, the National Guard may provide assistance with emergency medical response, decontamination, logistics, and transportation.22 For inter-regional transfer, please see Appendix E: Inter-Regional Transfers. 3.5.4 Patient Transfer Points To limit EMS personnel’s time in PPE to 3-3 ½ hours PTPs (either jurisdiction AHs or ETCs) have been identified along ground transportation routes. Each member of HHS Region V should establish agreements with the designated PTPs. A list of PTPs can be found in Appendix F: List of Region V Ground Transport Patient Transfer Points and a map in Appendix G: Map of Region V Ground Transport Patient Transfer Points. All transfer points should have the following capabilities:  Decontamination station for ambulance  Designated donning/doffing area  Designated area for personnel decontamination  Secure patient transfer zone  Category A waste disposal  Redundant communications  Provide basic care for the patient if medically necessary

21 “Funding Opportunity Announcement: Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities CFDA #93.817,” U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response, 2015, p 34. 22 FEMA. National Response Framework. 3rd Edition, June 2016, Accessed June 30, 2016, http://www.fema.gov/media-library-data/1466014682982- 9bcf8245ba4c60c120aa915abe74e15d/National_Response_Framework3rd.pdf.

3.6 Decontamination and Waste Management

3.6.1 Purpose This section of the Plan establishes guidelines related to best practice, procedure and regulations related to decontamination and waste management in relation to waste created during the care and transport of a patient with confirmed or highly suspected of EVD. 3.6.2 Situation Waste generated during the transport of a confirmed case of EVD is federally considered Division 6.2 Materials, Category A Infectious Substances (UN2814).23 Items deemed Category A waste include: medical equipment, sharps, linens, disposable PPE, all used health care products ranging from gauze to emesis basins, in addition to the transport vehicle. Category A waste is regulated by the U.S. Department of Transportation (USDOT) Hazardous Materials Regulations (HMR) 49 Code of Federal Regulations (CFR), 42 CFR Parts 72-73, and 29 CFR, Section 1910.1030. After a transport is completed and prior to doffing PPE, EMS personnel should at minimum, perform a gross decontamination of the ambulance and appropriately contain their waste. All Category A waste should be left at the PTP. PTPs without autoclaving capabilities should package the waste following USDOT requirements or in accordance with the special authorization permit issued to the waste management contractor or hauler by the USDOT.24,25 The packaged waste should be properly labeled and placed into a secure storage area until picked up by their waste management contractor.26 The Occupational Safety and Health Administration (OSHA) recommends that an Environmental Protection Agency (EPA)-registered disinfectant with label claims for use against non-enveloped viruses (e.g., norovirus, rotavirus, adenovirus, poliovirus) be used to treat contamination/spills and to disinfect non-porous surfaces after bulk spill material has been removed.27 Chemical treatment alone will not remove the Category A designation of the waste. Ebola-associated waste that has been appropriately incinerated, autoclaved, or otherwise inactivated is not infectious, does not pose a health risk and is not considered to be regulated medical waste or a hazardous material under federal law. Therefore, such waste is no longer considered Category A waste and is not subject to the HMR; 49 CFR, Parts 171-180.28, 29

23 HMR; 49 CFR §170-180. 24 HMR; 49 CFR §107. 25 “Hazmat Q&A,” PHMSA, accessed September 29, 2016, http://phmsa.dot.gov/hazmat/question-and-answer 26 “DOT Guidance for Preparing Packages of Ebola Contaminated Waste for Transportation and Disposal,” PHMSA, http://phmsa.dot.gov/staticfiles/PHMSA/DownloadableFiles/Files/suspected_ebola_patient_packaging_guidance_ final.pdf 27 “Fact Sheet: Safe Handling, Treatment, Transport and Disposal of Ebola-Contaminated Waste,” OSHA, National Institute for Occupational Safety and Health, U.S. Environmental Protection Agency, accessed March 25, 2016, https://www.osha.gov/Publications/OSHA_FS-3766.pdf. 28 “Ebola-Associated Waste Management,” CDC, updated February 12, 2015, accessed March 26, 2016 at http://www.cdc.gov/vhf/ebola/healthcare-us/cleaning/waste-management.html. 29 “Safety Advisory: Packaging and Handling Ebola Virus Contaminated Infectious Waste for Transportation to Disposal Sites,” DOT, accessed September 1, 2016 at http://phmsa.dot.gov/staticfiles/PHMSA/DownloadableFiles/Files/ebola_sa.pdf 21

3.6.3 Assumptions  Within the jurisdiction of each HHS Region V member, the treatment centers, assessment hospitals, frontline hospitals, and EMS have waste management policies and procedures in place for Ebola-associated waste that are compliant with all applicable federal and state laws.  Ebola waste appropriately sterilized by autoclave or incineration does not pose any health risks and can be handled as biohazard material disposed in a landfill not regulated by federal law.  PAG will follow their company policies and procedures regarding waste management and decontamination. 3.6.4 Concept of Operations Air Transport: There are several considerations in regards to waste management and decontamination depending on the mode of transport to the Region V RTC. The EMS agency transferring the EVD/HCID patient to Airport A cannot leave any waste generated during transport at a facility that cannot properly handle and store Category A waste. The ambulance crew must secure their waste in biohazard bags and then return to the closest facility with the ability to handle Category A waste and decontamination in accordance with their jurisdictional ConOps. During flight, PAG will follow their company policies and handle all waste generated during this leg of the journey. Local EMS accepting the patient from PAG personnel will not accept waste generated in flight. Local EMS transporting from Airport B to the Region V RTC will leave all waste at the RTC. A gross decontamination of the ambulance will occur at the Region V RTC (UMMC- West Bank) prior to EMS doffing their PPE. Complete decontamination will occur per the EMS agency policies and procedures. Ground Transport: During ground transport to the Region V RTC, each EMS agency involved will contain their waste and leave it at the PTP or end destination. All PTPs will agree to handle the Category A waste for EMS. At minimum, a gross decontamination of the vehicle will occur prior to EMS doffing their PPE or returning to their base station. EMS personnel can return to their base station for full decontamination if not performed at the PTP or end destination.

3.7 Provider Safety

3.7.1 Purpose This section is to provide guidance for ambulance protection, PPE and EMS personnel safety during transport. 3.7.2 Guidance The CDC has released guidance on safe practices for health care professionals caring for EVD patients to prevent EVD transmission during pre-hospital care, inpatient settings, and inter-facility transport. Standard Operating Procedures: Those EMS agencies identified to transport Ebola or other HCID patients should have SOPs specifically for transport of Ebola and HCID suspected or confirmed cases. The SOPs should address the following:  Adjusted list of required ambulance equipment  Ambulance preparation  PPE requirements, donning and doffing procedures  Waste management protocols and agreements  On scene and transport assessment and treatment guidelines including if a patient becomes unresponsive  Communication with health departments, law enforcement, and hospitals  Monitoring of personnel  Contingencies, i.e. transferring between two ambulances30 Personal Protective Equipment: The guidance below reflects lessons learned from the EVD outbreak of 2014-2016 and emphasizes the importance of training, practice, competence, and observation of personnel in correct donning and doffing procedures of PPE. As of August 27, 2015, the CDC recommends the following PPE to be used while caring for a patient with suspected or confirmed EVD:  Single-use (disposable) impermeable gowns extending at least to mid-calf OR single-use (disposable) coverall  Powered Air Purifying Respirators (PAPRs), or disposable, National Institute for Occupational Safety and Health (NIOSH) certified, N95 respirators with full face shield  Single-use (disposable) examination gloves with extended cuffs  Single-use (disposable) boot covers  Single-use (disposable) apron  Single-use (disposable) hood that extends to the shoulders and fully covers the neck31

30 “Guidance for Developing a Plan for Interfacility Transport of Persons Under Investigation or Confirmed Patients with Ebola Virus Disease in the United States,” CDC, updated January 28, 2016, accessed March 11, 2016, http://www.cdc.gov/vhf/ebola/health care-us/emergency-services/interfacility-transport.html 31 “Guidance on Personal Protective Equipment (PPE) to Be Used by Health care Workers During Management of Patients with Confirmed Ebola or Persons Under Investigation (PUIs) for Ebola who are Clinically Unstable or Have Bleeding, Vomiting, or Diarrhea in U.S. Hospitals, Including Procedures for Donning and Doffing PPE,” CDC, updated August 27, 2015, accessed December 9, 2015, http://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html. 23

In addition to appropriate PPE, the CDC highlights training as a vital part of protecting health care personnel, including EMS, from contracting HCIDs like EVD. CDC stresses repeated training with demonstrated PPE competency as essential in preventing transmission. Ambulance services willing to transport highly infectious disease patients should have regularly scheduled training specifically for PPE.

3.8 Mortuary Affairs

3.8.1 Purpose This section of the Plan is intended to provide guidance to EMS agencies if a patient dies during the transport process in an effort to prevent a postmortem transmission of EVD. 3.8.2 Situation Ebola can be transmitted postmortem; therefore, in the event of a patient death outside of the hospital setting during transport, EMS personnel must remain in full PPE until the body can be appropriately contained. Appropriate PPE must be worn when handling or exposed to human remains. 3.8.3 Assumptions  PAG will not divert their flight plan due to patient death. They will proceed with the scheduled flight plan and land in accordance with their flight plan and the State of Minnesota will assume responsibility for properly handling the remains unless otherwise instructed by the DOS.32  During ground transport, the state where the death is declared will assume responsibility for handling the remains per their jurisdictional ConOps.  If a body is transported between states, it will be completed in compliance with all state and local regulations and following CDC guidance (see 3.8.4-Mortuary Affairs Concept of Operations).  Human remains being transported for interment, cremation, or medical research at a college, hospital, or laboratory are exempt from the USDOT HMR 49 CFR, Parts 171-180.33 3.8.4 Concept of Operations If a confirmed EVD patient were to die during transport, the ambulance service’s actions are dependent on where they are in the transport process. If this were to occur, EMS should follow their normal protocol. If authorized, and it would take EMS personnel less time to return to the PTP where they started their leg of the journey, they should notify the PTP and turn back. However, if authorized and they are closer to the next PTP they should proceed to the next PTP to limit their time in PPE. If interstate transport is required, please coordinate with the CDC Emergency Operations Center at (770) 488-7100 and regional partners as needed.34

32 Minnesota will follow their State ConOps for Ebola/HCID when handling remains. 33 “Guidance for Safe Handling of Human Remains of Ebola Patients in U.S. Hospitals and Mortuaries,” CDC, updated February 11, 2015, accessed June 5, 2016, http://www.cdc.gov/vhf/ebola/healthcare- us/hospitals/handling-human-remains.html. 34 Ibid. 24

3.9 Medical and Legal Considerations

3.9.1 Transport Considerations  Any state through which a patient will be transported by ground will be notified through established procedures outlined above in Section 3.2-Communication and Coordination.  Any PTPs involved in ground transport will be notified by their respective jurisdictional authority.  All transports will be treated as non-emergent with no lights and sirens to limit attention, unless medically indicated. 3.9.2 Medical Treatment Considerations  During a ground transport, the receiving physician at the Region V RTC should be consulted along with the local EMS Medical Director with any deterioration in patient status.  The Memorandum of Transfer is signed by the sending physician and includes an inter-facility orders checklist.

4. Administration and Finance

4.1 Administration This section outlines general policies for administering resources. The Authorized Public Health and Health Care Agencies for each jurisdiction are listed in this plan and should be the reference point for policy and administration questions or changes.

4.2 Finance

4.2.1 Reimbursement Information for Treatment and Transport of EVD Patient35 The Ebola Supplemental Patient Care Reimbursement Program is authorized by the Consolidated and Further Continuing Appropriations Act, 2015, Public Law 113-235, Division G, Title VI, and section 311(c)(1) of the Public Health Service Act, 42 U.S.C. 243(c)(1). HHS/ASPR works with a third party vendor to assist with the processing of applications and the payment of authorized reimbursement amounts for the Program. The Act allows for “reimbursement of domestic transportation and treatment costs (other than costs paid or reimbursed by the individual’s health coverage) for an individual treated in the United States for Ebola, before or after the date of the enactment of this Act” at the HHS Secretary’s discretion. The Ebola Reimbursement Program may reimburse providers for domestic transportation and treatment costs incurred by the provider for patients with laboratory confirmed Ebola consistent with statutory authorities referenced above. Providers will not be eligible for reimbursement of transportation or treatment costs already covered by an individual’s insurance, and reimbursement will be limited to direct, uncompensated costs for caring for or transporting Ebola patients. Reimbursement for each professional claim (those submitted using the CMS-1500 form) will be calculated as the total value of allowed charges submitted by the practitioner—less any payments already received or to be received by the practitioner from other payers. Additional reimbursement for Extraordinary Direct Patient Care Staffing Costs:  Extraordinary direct patient care staffing costs are considered to be staffing costs above the normal staffing levels for the room and bed rate charges billed/reimbursed to date.  While it is anticipated reimbursement will be most applicable to hospitals, it is possible that patient transportation and other providers may have also experienced effort levels above the Relative Value Units (RVUs) normally set for a procedure.  Electronic copies in PDF format or hard copies of payroll records, time and attendance system records or other supporting documents are required for such a submittal.  The organization seeking reimbursement must provide as much narrative and supporting documentation as you deem necessary to document and explain these extraordinary direct staffing costs incurred while providing patient care or

35 H.R.83, Consolidate and Further Continuing Appropriations Act, 2015, https://www.congress.gov/113/plaws/publ235/PLAW-113publ235.pdf

supporting the environment of care for confirmed Ebola-infected patients and why they are not fully reimbursed as part of payments received to date from other payers. 4.2.2 Ebola Treatment Reimbursement Program for U.S. Hospitals36 Any provider that has treated or transported a patient with Ebola is eligible for reimbursement. The federal government agreed to reimburse hospitals because several hospitals around the country treated patients with confirmed cases of Ebola disease and incurred unusual expenses in delivering that care. Congress appropriated funds to be used for “reimbursement of domestic transportation and treatment costs for an individual treated in the United States for Ebola.” The Hospital or transportation provider must seek reimbursement for care from the private insurance company prior to submitting the reimbursement claim to HHS. Generally, eligible expenses will be limited to the direct costs of care not already covered by other methods of reimbursement, including, but not limited to:  All clinical care and interventions  Increased staffing costs  Personal protective equipment  Waste management, removal, and disposal  Increased laboratory costs, including expenses of shipping of samples  Patient transport costs The following expenses are ineligible for reimbursement:  Costs already covered by other methods of reimbursement (e.g. insurance)  Training  Facility modification  Lost revenue  Increased security  Post exposure monitoring of staff, etc. Under this authority, HHS will reimburse for direct, uncompensated costs for caring for or transporting Ebola patients using funds appropriated to the Public Health and Social Services Emergency. HHS will reimburse the full difference between calculated costs and payments received. HHS will reimburse any “extraordinary” costs at 102% to account for increased administrative efforts and other indirect expenses associated with the care of Ebola patients.

36 Ibid.

5. Training and Exercise

5.1 Training

5.1.1 Training Plan Development As with all plans, individuals and agencies must understand their specific role as applicable to this Plan. Operations must be coordinated with local, state, and regional partners as applicable. Each jurisdiction is responsible for ensuring adequate training for their respective jurisdiction under their ConOps. This includes frontline hospital, AH, ETC, first response (e.g. police, fire etc.), and EMS personnel training. Effective training is sustainable in nature and documented. Documentation will assist in identifying knowledge gaps in order to modify and tailor training to meet needs. Jurisdictions may choose to send staff of assessment hospitals or treatment centers to train at NETEC. The Region V RTC will continue to train their Ebola and Special Pathogens Unit staff quarterly. 5.1.2 Training Plan Implementation A Training and Exercise (T & E) committee will be formed via the GLHP. As much as possible, training on this plan will be coordinated through MDH with the Region V RTC. Each jurisdiction is responsible for ensuring the appropriate jurisdictional training is completed to maintain awareness and ensure optimal outcomes.

5.2 Exercise

5.2.1 Exercise Plan Development Annual exercise of this plan and all jurisdictions’ ConOps is mandated as outlined in the Funding Opportunity Announcement: Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities (CDFA #93.817). 5.2.2 Exercise Plan Implementation The Training and Exercise subcommittee of the GLHP will coordinate an annual exercise for HHS Region V inclusive of UMMC-West Bank. At minimum all jurisdictions will complete a notification drill with MDH and UMMC-West Bank annually. Over the five year grant period the annual exercises will increase in size and scale as follows:  Year 1: Each jurisdiction will exercise their respective individual ConOps  Year 2: Each jurisdiction will participate in a regional communication virtual Table Top Exercise  Year 3: Each jurisdiction will participate in a regional virtual Table Top Exercise  Years 4 and 5: Each jurisdiction will participate in an annual virtual Table Top, functional, or full-scale regional exercise in coordination with their city/state plan When applicable HHS Region V will incorporate PAG for air transport coordination in these drills. Each individual member of HHS Region V is required to maintain their own exercise plan and after-action report.

5.2.3 Select HPP Ebola Grant Performance Measures for Regional Transport37

ASPR Grant Grant Performance Measure Part Activity Measure No. Time, in minutes, it takes from an assessment hospital’s notification to the health department of the need for an inter-facility transfer of a patient with confirmed Ebola 1 A A to the arrival of a staffed and equipped EMS/inter-facility transport unit, as evidenced by a no-notice exercise (Goal: Within 240 minutes or 4 hours) Time from confirmation of Ebola patient at assessment hospital or ETC to notification by the health department and/or transferring hospital (assessment hospital or ETC) 19 B A to the health department in the state/jurisdiction where the regional Ebola and other special pathogen treatment center is located about the need for patient transfer (Goal: Within 30 minutes). Proportion of states/jurisdictions in the HHS region that have demonstrated the ability to move a patient across 22 B A jurisdictions by ground or air to a regional Ebola and other special pathogen treatment center (Goal: 100%) Time until a regional Ebola and other special pathogen treatment center is ready to admit a patient with 26 B B confirmed Ebola (adult or pediatric patient), as evidenced by an exercise or actual patient transfer (Goal: Within 8 hours of notification)

37 “Measurement Implementation Guidance: Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities CFDA #93.817,” U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response, 2015. 29

6. Plan Development, Maintenance, and Review

6.1 Development

6.1.1 Lead Agencies MDH and the GLHP are responsible for coordinating emergency planning related to this Plan. 6.1.2 Supporting Agencies There are several supporting agencies involved in the development and maintenance of this Plan.  Each jurisdiction’s authorized public health and health care representative is responsible for supporting emergency planning.  ASPR/Office of Emergency Management HPP Project Officer and RECs are responsible for assisting MDH with the facilitation of planning efforts, providing input into operational planning, and providing guidance on ASPR policies and requirements.  The University of Minnesota Medical Center-West Bank Campus is responsible for reviewing the Plan and providing operational input as warranted.  All Region V assessment hospitals and Ebola treatment centers are responsible for reviewing the Plan per their jurisdictional authorized public health and health care lead agency.  An identified CDC representative will be consulted as needed.

6.2 Maintenance 6.2.1 Requirements This Plan will be maintained and distributed by the Minnesota Department of Health in coordination with the GLHP. It will be kept on the GLHP SharePoint© page, which is maintained by the GLHP Project Manager. Review and distribution of the Plan will be coordinated by MDH and the GLHP Project Manager. In compliance with ASPR’s HPP Ebola Preparedness and Response Activities (CFDA #93.817), each Region V partner will exercise their respective ConOps annually. Therefore, each jurisdictional ConOps as well as the Regional Coordination and Transportation Plan will be reviewed and updated if needed annually. Directors of the supporting agencies are responsible for updating their respective internal plans and for working within the GLHP to ensure a prompt and effective response to an emergency or disaster.

6.3 Review and Update 6.3.1 Review The Plan will be reviewed every year with input from HHS Region V health departments, the GLHP, and necessary subject matter experts (SMEs). The review will occur either after an activation of the Plan or at least annually. The review process will incorporate lessons learned from an activation and any new planning developments.

6.3.2 Updates and Changes Updates and changes to the Plan may be necessary both at the Regional level and jurisdictional level. If a jurisdiction needs to make an update to the Plan related to their jurisdiction, they should contact the GLHP Project Manager to do so. The changes should be recorded and the revised plan distributed. Updates that require the signatures of the Authorized Public Health and Health Care Agency representatives will be completed during the annual review process. All changes to the Plan will be done in concert with all relevant agencies before a formal revision is made. Revisions to the Plan will be completed and distributed by December 31st of each year.

7. Authorities and References

7.1 Legal Authority 7.1.1 Federal 1. Pandemic and All-Hazards Preparedness Reauthorization Act (PAPRA) 2. The National Response Framework 3. The Robert T. Stafford Disaster Relief and Emergency Assistance, Public Law 93- 288 as amended 4. Consolidated and Further Continuing Appropriations Act, 2015, Public Law 113- 235, Division G, Title VI, and section 311(c)(1) of the Public Health Service Act, 42 U.S.C. 243(c)(1) 7.1.2 Jurisdiction Each member of HHS Region V must adhere to the legal authorities of their own jurisdiction.

7.2 References 7.2.1 Federal 1. ASPR’s Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities (CFDA #93.817) 2. ASPR’s National Ebola Training and Education Center (NETEC) Cooperative Agreement (EP-U3R-15-003) 3. ASPR Ebola Preparedness 2015 HPP Measurement Implementation Guide 4. FEMA. National Response Framework. 3rd Edition, June 2016, Accessed June 30, 2016, http://www.fema.gov/media-library-data/1466014682982- 9bcf8245ba4c60c120aa915abe74e15d/National_Response_Framework3rd.pdf. 5. “Guidance on Personal Protective Equipment (PPE) to Be Used by Healthcare Workers During Management of Patients with Confirmed Ebola or Persons Under Investigation (PUIs) for Ebola who are Clinically Unstable or Have Bleeding, Vomiting, or Diarrhea in U.S. Hospitals, Including Procedures for Donning and Doffing PPE,” CDC, updated August 27, 2015, accessed December 9, 2015, http://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html. 6. HRM; 49 CFR, “Transportation.” http://www.ecfr.gov/cgi-bin/text- idx?tpl=/ecfrbrowse/Title49/49tab_02.tpl 7. OSHA. “Fact Sheet: Safe Handling, Treatment, Transport and Disposal of Ebola- Contaminated Waste,” OSHA, National Institute for Occupational Safety and Health, U.S. Environmental Protection Agency, accessed March 25, 2016, https://www.osha.gov/Publications/OSHA_FS-3766.pdf. 8. H.R.83, Consolidate and Further Continuing Appropriations Act, 2015 https://www.congress.gov/113/plaws/publ235/PLAW-113publ235.pdf 7.2.2 Jurisdiction Each member of HHS Region V maintains their own reference documents.

Appendices

Appendix A: Abbreviations and Acronyms Abbreviation or Definition Acronym AH Assessment Hospital AM/DAM Active Monitoring/Direct-Active Monitoring ASPR Assistant Secretary for Preparedness and Response AST/ALT Amiotransferase enzymes BETP Bureau of Emergency Medical Services, Trauma and Preparedness BOL Bureau of Laboratory (Michigan) CBC Complete Blood Count CCME Cook County Medical Examiner CD Communicable Disease CDC Centers for Disease Control and Prevention CDPH Chicago Department of Public Health CERN Chicago Ebola Response Network CFR Code of Federal Regulations ConOps Concept of Operations CPD Chicago Police Department CSM Cremation Society of Minnesota DEPR Division of Emergency Preparedness and Response DNR Do Not Resuscitate DOS U.S. Department of State DTW Detroit Metropolitan Airport ED Emergency Department EMG SOC and ASPR’s Emergency Management Group EMS Emergency Medical Services EMSRB Minnesota Emergency Medical Services Regulatory Board EMTALA Emergency Medical Treatment and Labor Act EOC Emergency Operations Center Epi-X Epidemic Information Exchange ESF Emergency Support Function ETC Ebola Treatment Center EVD Ebola Virus Disease FEMA U.S. Federal Emergency Management Agency FH Frontline Hospital FOA Funding Opportunity Announcement GLHP Great Lakes Health Care Preparedness Partnership HCID High Consequence Infectious Disease HCME Hennepin County Medical Examiner’s Office HCT Hematocrit Hgb Hemoglobin

Abbreviation or Definition Acronym HHS U.S. Department of Health and Human Services HIPAA Health Insurance Portability and Accountability Act HMR Hazardous Material Removal HPP Hospital Preparedness Program HSEM Minnesota Homeland Security and Emergency Management Agency IDEPC Infectious Disease Epidemiology, Prevention and Control IDPH Illinois Department of Public Health IEMS Indiana Emergency Medical Services INEDSS Illinois National Electronic Disease Surveillance System INR International Normalized Ratio ISDH Indiana State Department of Health LPH Local Public Health LRN Laboratory Response Network MAC Metropolitan Airports Commission MDH Minnesota Department of Health MDHHS Michigan Department of Health and Human Services ME Medical Examiner MFC Metro First Call MHA Minnesota Hospital Association MN Minnesota MOU Memorandum of Understanding MPCA Minnesota Pollution Control Agency MSP Minneapolis-Saint Paul International Airport NETEC National Ebola Training and Education Center NIOSH National Institute for Occupational Safety and Health OEMC (City of Chicago’s) Office of Emergency Management and Communications ORD Chicago O’Hare International Airport OSHA Occupational Safety and Health Administration PAG Phoenix Air Group, Inc. PAPR Powered Air Purifying Respirator PCR Polymerase chain reaction PPE Personal Protective Equipment PSA Primary Service Area PSAP Public Safety Answering Points PTP Patient Transfer Point PUI Person Under Investigation REC Regional Emergency Coordinator RST Rochester International Airport RTC Regional Treatment Center SOC HHS Secretary’s Operations Center SOP Standard Operating Procedure

Abbreviation or Definition Acronym STP St. Paul Downtown Airport T & E Training and Exercise TEAM Traveler Evaluation and Monitoring UMMC-West Bank University of Minnesota Medical Center—West Bank Campus USDOT U.S. Department of Transportation WI DPH Wisconsin Division of Public Health WSLH Wisconsin State Lab of Hygiene

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Appendix B: Jurisdiction Capabilities A. City of Chicago (as of December 1, 2016) 1. Authorized Public Health and Health Care Coordinating Agency: Chicago Department of Public Health (CDPH) 2. Primary Point of Contact: 24/7 on-call CDPH Medical Director can be reached by calling 311 within the City of Chicago, or 312-744-5000 outside of Chicago 3. Active Monitoring/Direct Active Monitoring:  CDPH is responsible for monitoring of persons at risk for EVD in Chicago. CDPH receives Epi-X traveler data from Illinois Dept. of Public Health (IDPH), validates data, enters into the Illinois National Electronic Disease Surveillance System (INEDSS), and onto an internal monitoring spreadsheet. CDPH then assigns a Public Health Nurse to monitor for symptoms suggestive of EVD. CDPH collects temperature and symptom data twice daily for 21 days, and enters into INEDSS. After 21 days, CDPH closes the case in INEDSS. o For low, but not zero risk: CDPH makes 1x weekly in-person visits and receives temperatures twice daily via phone o For some risk: CDPH makes 1x daily in-person visits and receives second temperature via phone o For high risk: CDPH makes 2x daily in-person visits to collect temperature and symptom data  If the person travels away from Chicago: o In-state travel: Case is transferred in INEDSS o Out-of-state travel: IDPH makes Interstate Notification via Epi-X o International travel: Traveler presents to U.S. Embassy  If non-compliant, CDPH Monitor notifies the Coordinator and/or AM/DAM Physician after 24 hours of lost contact. The Coordinator contacts traveler, emergency contacts, and monitors traveler’s social media. If no response, CDPH contacts Chicago Police Department (CPD) to assist with home delivery of Letter of Non-Compliance. 4. EMS:  To date, there are six designated EMS transport companies in Chicago. One is the Chicago Fire Department (CFD) EMS for transports originating from the community (911 call) or airport, and five are private EMS companies for facility to facility transports.  Along with IDPH and the Regional Hospital Coordinating Center (RHCC) for Chicago, CDPH will provide guidance to EMS and help coordinate safe transport of a PUI or confirmed case to a Chicago Ebola Response Network (CERN) hospital, which are the designated ETCs for Chicago.

5. Transport from Chicago to the Region V RTC:  AIR TRANSPORT: o Preferred mode of transportation from a hospital in Chicago to the University of Minnesota Medical Center o Designated Airport: Chicago O’Hare International Airport (ORD) o CDPH would contact the HHS Region V REC, who will make the appropriate notifications regarding air transport. CDPH would coordinate with the sending hospital, which would use one of the designated EMS providers to transport the patient to Chicago O’Hare International (ORD) airport. The HHS Region V REC, along with the City of Chicago Office of Emergency Management and Communications (OEMC), would then coordinate air transport from O’Hare to Minneapolis. The CDC Chicago Quarantine Station at O’Hare airport should be notified for awareness, in the case of an air transport.  GROUND TRANSPORT: o CDPH will work with the Minnesota Department of Health and other involved HHS Region V health departments, as well as the HHS Region V REC and HPP Project Officer to confirm the logistics and details of ground transport to the Region V RTC in Minneapolis. Items to be addressed prior to the initiation of ground transport include, but are not limited to: 1. Route  Patient Transfer Points (PTPs)  EMS agencies and their leg of journey 2. Communications while in route 3. Contingencies 6. Hospital System:  All health care facilities in Chicago, including hospitals, ambulatory care, urgent care settings, outpatient clinics, specialty hospitals, emergency departments, etc. are considered frontline health care facilities.  In addition, all licensed hospitals should be prepared to appropriately screen and provide basic supportive care to any suspected or confirmed EVD patient, consistent with the Emergency Medical Treatment and Labor Act (EMTALA). Hospitals should have enough PPE for a minimum of up to 8 hours of care, until the patient is transferred to a CERN hospital.  Ebola Treatment Centers or CERN Hospitals-(3) o Ann & Robert H. Lurie Children’s Hospital of Chicago—Chicago, IL o Northwestern Memorial Hospital—Chicago, IL o Rush University Medical Center—Chicago, IL 7. Waste Management:  All of the CERN hospitals have a contract with Stericycle® for deactivation and disposal of Category A waste. CERN hospitals will ensure that Stericycle®, or whichever company is contracted, has a valid USDOT permit for transport of waste.  After patient transport, EMS will remove isolation tents or plastic coverings, perform a gross decontamination with wipes as necessary, and remove PPE. Hospitals will provide appropriate biohazard waste disposal receptacles for waste,

a safe space for doffing PPE, and a trained observer if available (if EMS does not provide their own trained observer). o CFD: EMS companies and paramedics will then leave the hospital ambulance receiving point and follow their own general orders concerning returning back to normal operations. o Private EMS provider (in or out of state): ambulance and paramedics will return to their agency station for full decontamination if necessary, or coordinate with CDPH to identify an alternative location for full decontamination. 8. Fatality Management:  CDPH and the CERN hospitals will follow CDC guidance as feasible. CDPH’s role is to help provide consult, coordination, and materials and supplies (e.g. body bags, PPE, etc.) to health care facilities. CDPH will also contact IDPH, CDC and the Cook County Medical Examiner’s (CCME) office for consultation, including legal counsel.  As the medical examiner in the jurisdiction, the CCME has authority over the deceased. If confirmed with EVD, the CCME will not perform an autopsy. The body will be transported directly to a designated funeral home/crematorium. If the CCME is notified of a suspicious death potentially from EVD, the office will reach out to CDPH and CDC for consultation. In the event of a suspected case of EVD, autopsies should be avoided until another cause is determined. Once a diagnosis is determined, proper body containment and assessment for appropriate disposition will be initiated under the advice of the Chief Medical Examiner along with other appropriate agencies and next-of-kin.  Any facility should notify CDPH immediately in the case of an EVD deceased patient for further guidance, including measures to take if the body is not claimed. CDPH is in the process of designating and developing agreements with funeral homes/crematoriums to handle the transportation and disposition of remains for any EVD-related deaths in the jurisdiction. Per state law, EMS cannot transport a deceased body. 9. Laboratory:  CERN hospitals’ clinical laboratories are prepared to provide timely and sufficient diagnostic testing to ensure patient care is not compromised, and medical evaluation is not delayed while patients undergo assessment prior to availability of EVD laboratory testing results.  CERN hospitals have determined specific testing according to the patient presentation and travel history, and have demonstrated how they would perform these laboratory tests safely. This testing includes a complete blood count (CBC); glucose and potassium concentrations; malaria testing (smear or rapid tests); and testing for influenza virus and liver function.  Laboratories in Chicago are prepared to send EVD specimens to IDPH Division of Laboratories for EVD PCR testing, after consultation with CDPH. CDC will provide confirmatory testing on any specimens that test positive at IDPH lab. Laboratories should follow IDPH’s Division of Laboratories guidance when sending specimens.

B. Illinois (as of December 1, 2016) 1. Authorized Public Health and Health Care Coordinating Agency: Illinois Department of Public Health (IDPH) 2. Primary Point of Contact: 24/7 Office of Preparedness and Response Duty Officer at 217- 782-7860 (in-state calls) and 1-800-782-7860 (out of state calls) 3. Active Monitoring/Direct Active Monitoring:  Local public health assumes responsibility for establishing communications with the potentially exposed individuals, includes daily check-ins. Clinical criteria will determine if the person needs to have direct observation or can submit temperatures and symptoms consistent with Ebola 4. EMS:  14 designated EMS transport services in Illinois  EMS will identify and assess a patient for symptoms of Ebola, may be notified by arranging Local Health Department who has been monitoring patient, a point of Entry, or a 9-1-1 call.  Notification is made to the receiving facility that a potential Ebola patient will be arriving at their facility through normal every day communications, IDPH has put a waiver system in place for any EMS agencies will to strip down their ambulances may do so to attempt to minimally expose any equipment in the ambulance unnecessarily. EMS agencies also follow IDPH Guidelines for preparing an ambulance for Patients who may meeting criteria for a Diagnosis of Ebola. 5. Transport from Illinois to the Region V RTC:  Individual regions within the state have their own regional ground transport plans; any transports across regions will be in coordination with the Local Health Department, State Health Department, transferring/receiving hospitals and appropriate staff.  AIR TRANSPORT: o Preferred mode of transportation from a hospital in Illinois to the University of Minnesota Medical Center o Designated Airport: Chicago O’Hare International Airport (ORD)  GROUND TRANSPORT: o IDPH will work with the Minnesota Department of Health and other involved HHS Region V health departments, as well as the HHS Region V REC and HPP Project Officer to confirm the logistics and details of ground transport to the Region V RTC in Minneapolis. Items to be addressed prior to the initiation of ground transport include, but are not limited to: 1. Route  Patient Transfer Points (PTPs)  EMS agencies and their leg of journey 2. Communications while in route 3. Contingencies

6. Hospital System:  There are 7 Ebola Assessment Hospitals in Illinois. All ETCs currently are in the City of Chicago. The AHs are prepared to handle care for an Ebola patient or PUI for up to 4 days before transfer to an ETC. This would allow for care to be provided while tests for Ebola and other infectious diseases are being completed.  Assessment Hospitals-(7) o Carle Foundation Hospital—Urbana, IL o FHN Memorial Hospital—Freeport, IL o Good Samaritan Regional Health Center—Mt. Vernon, IL o OSF St. Francis Medical Center—Peoria, IL o Rockford Memorial Hospital—Rockford, IL o SIH Memorial Hospital of Carbondale—Carbondale, IL o St. John’s Hospital—Springfield, IL  State Ebola Treatment Centers or CERN Hospitals-(3) o Ann & Robert H. Lurie Children’s Hospital of Chicago—Chicago, IL o Northwestern Memorial Hospital—Chicago, IL o Rush University Medical Center—Chicago, IL 7. Waste Management:  Within Illinois all AHs and CERN hospitals have a contract with a waste management company for deactivation and disposal of Category A waste. CERN hospitals will ensure that Stericycle®, or whichever company is contracted, has a valid USDOT permit for transport of waste.  After patient transport local EMS will perform a gross decontamination in designated area at the receiving hospital. The receiving hospital will also accept all waste generated during patient transport from EMS.  Out of State EMS agency will perform a gross decontamination in designated area at the receiving hospital. The receiving hospital will also accept all waste generated during patient transport from EMS. 8. Fatality Management:  Within the state of Illinois and City of Chicago, paramedics/EMTs are required to abide by state coroner’s laws when there’s a death during transport.38  If during transport the patient begins to decline and does not have a Do Not Resuscitate (DNR) order, resuscitation efforts will begin, and the patient is to be taken to the closest hospital capable of managing Category A waste.  If during transport the patient with an active DNR order begins to decline and death is imminent, EMS should communicate with the closest hospital capable of managing Category A waste and notify the county coroner in which the patient is currently in. Arrangements can be made to meet the coroner at the hospital or secure location such as a fire station in order to make the declaration of death.  Due to County and jurisdictional rules, the coroner of the county in which the patient has expired is required to make a determination of death as well as where and when the body would be properly handled for processing and cremation.

38 Illinois Compiled Statutes, “55 ILCS 5/3-3013 Ch. 34, par. 3-3013,” http://www.ilga.gov/legislation/ilcs/fulltext.asp?DocName=005500050K3-3013. 41

 No deceased patient should be transported across state lines, communication should be made to the county coroner and declaration can be made and decisions about proper disposition of the deceased.  The body will be held in a secure location until arrangements are made for disposition. 9. Laboratory:  All lab services for AHs and ETCs are per CDC guidelines. All AHs should have a laboratory menu that could rule out malaria, perform a CBC, complete metabolic panel, prothrombin time, and an INR if necessary.  The state IDPH lab has the ability to test and confirm an Ebola sample without sending it to CDC.

C. Indiana (as of December 1, 2016) 1. Authorized Public Health and Health Care Coordinating Agency: Indiana State Department of Health (ISDH) 2. Primary Point of Contact: Main Line (24/7) 317-233-1325 3. Active Monitoring/Direct Active Monitoring:  ISDH will implement DAM for persons having travel within the past 21 days to a county identified by the CDC having widespread Ebola transmission, consisting of twice daily monitored temperature checks.  For all other highly infectious diseases, the ISDH may implement AM/DAM or self- monitoring based upon the recommendations of the CDC. 4. EMS:  Each of Indiana’s 10 District Health Care Coalitions have identified EMS agencies designated to transport Ebola/HCID patients to the nearest appropriate facility.  Statewide, Indiana has identified the Indianapolis Emergency Medical Services (IEMS) as the primary statewide EMS transport.  Upon a PUI or confirmed Ebola or other highly infectious disease case, the local health department or local hospital notifies the ISDH Provider Line.  The ISDH establishes a conference call with the local health department, local hospital, appropriate Ebola/Infectious Disease assessment hospital, local EMS or IEMS, and other pertinent partners to discuss and develop transportation plan. 5. Transport from Indiana to the Region V RTC:  Prior to this Plan activation, Indiana will communicate with their State EOC and the PHEP Project Officer.  If following a ISDH joint conference call a determination requiring transport is made, the appropriate local EMS will provide transportation to the nearest appropriate AH. There a patient will wait while additional plans are made to transport the patient via air or ground.  AIR TRANSPORT: o Preferred mode of transportation from a hospital in Indiana to the University of Minnesota Medical Center o Upon confirmation of Ebola or other HCID requiring treatment at the Region V RTC, transportation will be arranged by local EMS or IEMS to the nearest appropriate airport o Designated Airport(s): To Be Determined  GROUND TRANSPORT: o ISDH will work with the Minnesota Department of Health and other involved HHS Region V health departments, as well as the HHS Region V REC and HPP Project Officer to confirm the logistics and details of ground transport to the Region V RTC in Minneapolis. Items to be addressed prior to the initiation of ground transport include, but are not limited to:

1. Route  Patient Transfer Points (PTPs)  EMS agencies and their leg of journey 2. Communications while in route 3. Contingencies 6. Hospital System:  Indiana has over 160 hospitals through the state. All of Indiana hospitals, as well as ambulatory surgical centers, rural health clinics, and other health care facilities make up the state’s Frontline Facilities.  Indiana has 6 Assessment Hospitals, geographically covering the State to limit the drive time from any location within the State to 90-120 minutes.  Indiana does not have any treatment centers specific for Ebola, but many have the capability for the treatment of other HCIDs.  Assessment Hospitals-(6) o Good Samaritan Hospital—Vincennes, IN o IU Methodist—Indianapolis, IN o Schneck Medical Center—Seymour, IN o St. Joseph Regional—Mishawaka, IN o St. Vincent—Indianapolis, IN o Union Hospital—Terre Haute, IN 7. Waste Management:  When transporting a suspected or confirmed Ebola case, EMS treat all PPE, supplies, equipment, and apparatus as Category A waste until negative confirmation.  All waste produced by the transport of EMS will be disposed of at the appropriate AH. Category A waste will be disposed by the AH in accordance with CDC and USDOT guidelines.  EMS transporting to an airport will return to the appropriate AH to properly dispose of waste. 8. Fatality Management:  A patient dying while being transported will be transported to the AH and the appropriate fatality protocols followed by the AH.  A patient dying while being transported to an airport will return to the in-state AH and the appropriate fatality protocols followed by the AH. 9. Laboratory:  The ISDH Laboratory has the capability to perform Ebola testing as well as many other HCIDs. Hospitals are able to submit samples for testing.  Tests unable to perform will be sent and coordinated with the CDC.

D. Michigan (as of December 1, 2016) 1. Authorized Public Health and Health Care Coordinating Agency: Michigan Department of Health and Human Services (MDHHS), Bureau of EMS, Trauma and Preparedness (BETP) 2. Primary Point of Contact: Duty Officer, 517-819-0391 3. Active Monitoring/Direct Active Monitoring:  The Traveler Evaluation and Monitoring (TEAM) Protocol (http://www.michigan.gov/documents/emergingdiseases/TEAM_Protocol_498923 _7.pdf?20160608113428) will be followed. o Contact the Surveillance of Infectious Disease Section: 517-335-8165 (Business Hours), 517-335-9030 (After Hours).  MDHHS will be notified on a daily basis via Epi-X about all travelers departing from Ebola impacted countries and arriving at U.S. designated ports of entry.  Local Health Departments (LHD) provide active monitoring and direct active monitoring per TEAM protocol. Symptomatic travelers will be referred to pre- designated hospitals. The TEAM log is retained by the Michigan regional epidemiologist and MDHHS.  Active Monitoring o Making contact with the traveler once daily by phone, e-mail, electronic visualization, or in person to check on health status. All updates are recorded on the TEAM log.  Direct Active Monitoring o Making contact with the traveler twice daily to check on health status. One of the two contacts must be in person or through electronic visualization to directly observe the individual. All updates are recorded on the TEAM log. 4. EMS:  Fifteen (15) EMS agencies have agreed to transport patients with Ebola or Special pathogens. At least 1-2 transport agencies are located in each of the 8 Michigan Emergency Preparedness regions.  Travelers who are being monitored are reminded daily by LHD to notify EMS or health care providers of their monitoring status should the traveler seek medical care or transport. A pre-designated assessment or treatment hospital will be identified and notified if a traveler becomes symptomatic.  Activation of EMS transport is coordinated through MDHHS and the Regional Health Care Coalition Medical Coordination Center (MCC) with the designated EMS transport agency located within regional proximity to the patient location. 5. Transport from Michigan to the Region V RTC:  Patients would be transferred from one of six ETCs within the state of Michigan. Transport would be coordinated during a pre-transport meeting with all parties involved with the care of the patient and would be via one of the 15 EMS agencies trained to transport and care for Ebola/HCID patients.  AIR TRANSPORT: o Preferred mode of transportation from a hospital in Michigan to the University of Minnesota Medical Center o Designated Airports: Detroit (DTW) and Grand Rapids (Gerald R. Ford)

 GROUND TRANSPORT: o MDHHS will work with the Minnesota Department of Health and other involved HHS Region V health departments, as well as the HHS Region V REC and HPP Project Officer to confirm the logistics and details of ground transport to the Region V RTC in Minneapolis. Items to be addressed prior to the initiation of ground transport include, but are not limited to: 1. Route  Patient Transfer Points (PTPs)  EMS agencies and their leg of journey 2. Communications while in route 3. Contingencies 6. Hospital System:  All hospitals in Michigan have self-identified a Tier status. There are six (6) Tier 1 and 2 (treatment) facilities, thirty-one (31) Tier 3 (assessment) facilities, and one hundred thirty-one (131) Tier 4 (frontline) hospitals.

 All hospitals receive technical site visits from trained BETP staff to provide assistance with mitigation of gaps identified.

 Assessment Hospitals-(24) o McLaren Greater Lansing—Lansing, MI o Sparrow Health System—Lansing, MI o Mount Clemens Regional Medical Center —Mt. Clemens, MI o McLaren Oakland—Pontiac, MI o McLaren Port Huron Hospital—Port Huron, MI o St. John Providence Hospital & Medical Center —Southfield, MI o St. John Macomb - Macomb Center—Warren, MI o St. John Macomb - Oakland Center—Madison Heights, MI o St. Joseph Mercy Port Huron—Huron, MI o Garden City Hospital—Garden City, MI o St. John Hospital & Medical Center—Detroit, MI o Covenant Medical Center—Saginaw, MI o Hurley Medical Center—Flint, MI o Mclaren Lapeer Region—Lapeer, MI o MidMichigan Medical Center—Midland, MI o Borgess Medical Center—Kalamazoo, MI o Bronson Methodist Hospital—Kalamazoo, MI o Holland Hospital—Holland, MI o Mercy Health, Saint Mary's—Grand Rapids, MI o North Ottawa Community Hospital—Grand Haven, MI o Munson Healthcare Grayling Hospital—Grayling, MI o Munson Medical Center—Traverse City, MI o McLaren Northern Michigan Regional Hospital—Petoskey, MI o Marquette General Health System—Marquette, MI  State Ebola Treatment Centers-(6) o St. Joseph Mercy Oakland—Pontiac, MI o Detroit Receiving & University Health Center—Detroit, MI o Henry Ford Hospital—Detroit, MI o Beaumont Hospital, Wayne—Wayne, MI o St. Joseph Mercy Hospital Ann Arbor—Ypsilanti, MI o Spectrum Health, Butterworth Campus—Grand Rapids, MI 7. Waste Management:  Waste generated during patient care within a hospital, during, or after transport will be managed through existing hospital waste management procedures that includes a Category A Waste Transporter.  Waste accumulated during EMS transport will be disposed of at Tier 1 or 2 hospitals.  The location for ambulance decontamination will be identified before patient transport.

8. Fatality Management:  EMS transport is done with coordination of the BETP team. Special precautions have been taken to identify patients and work with treatment hospitals for proper transport. In addition, Michigan is working to identify crematoriums that will accept Ebola/special pathogen patients, working to establish protocols for transfer of the deceased remains safely, and training on Bio-Seal system to contain body fluids during transport.  No state laws restrict movement of a body with suspected communicable disease.  Prior to transport of a patient, the route of transport will be identified. This plan will include notification of all hospitals within the designated route if the patient becomes unstable or expires. If a patient should expire during a transport, the transfer will not be completed. Depending on the geographic location of the ambulance, the body may be returned to the facility of origin, taken to a designated crematorium, or taken to the hospital designated during the preparation of the route. 9. Laboratory:  EVD testing is available at the MDHHS Bureau of Laboratories (BOL) and is available 7 days a week. Results are available within 24 hours of specimen receipt.  Prior to EVD testing by the state lab, test results from the following are requested in order to evaluate the patient before approval for testing: Platelet count, AST/ALT, INR, Creatinine, Hgb/HCT, Malaria. NOTE: Blood films, suspicious for Malaria can be forwarded to MDHHS BOL for confirmation. Confirmation may include PCR from submitted blood samples.

E. Minnesota (as of December 1, 2016) 1. Authorized Public Health and Health Care Coordinating Agency: Minnesota Department of Health (MDH) 2. Primary Point of Contact: Emergency Preparedness and Response On Call, 651-201-5735 3. Active Monitoring/Direct Active Monitoring:  MDH has previously developed a protocol and infrastructure to conduct monitoring. Monitoring protocols and resources will be adapted per CDC guidelines and situation specific recommendations.  Monitoring will take place for 21 days past the last possible exposure to Ebola and can occur on a voluntary basis or may be required by public health order (depending on the risk status of the traveler).  Individuals who do not comply with monitoring are subject to: possible legal action including quarantine, isolation, Do Not Board orders (restricting ability to fly), or other restrictions on their movement or activities. Non-compliant individuals will be handled on a case-by-case basis.  Active Monitoring o Individuals being monitored must take their temperature twice daily, watch themselves for symptoms, and immediately tell public health officials if they have a fever or other symptoms. o Public health officials are responsible for checking at least once a day to see if individuals have a fever or other symptoms of Ebola.  Direct Active Monitoring o Public health officials conduct monitoring by directly observing the person. This means that a public health official directly observes the person at least once a day to review symptoms and check their temperature. o Direct observation can be through electronic means (Skype, Facetime). A second follow-up per day can be done by telephone instead of being directly observed. 4. EMS:  Minnesota has over 300 licensed ambulance service providers. There are seven (7) identified “Ebola or other HCID Ready” ambulance services capable and willing to transport Ebola or HCID patients. Criteria to be an “Ebola/HCID Ready” EMS agency includes training, resources, SOPs, and ability to maintain normal operations for service area while transporting (see Minnesota State ConOps for Ebola for details).  Three (3) EMS agencies are designated to pick up at the designated airports willing to accept a PAG fixed-wing air ambulance:39 o Downtown Saint Paul Airport (STP)- HealthEast EMS o Minneapolis-Saint Paul International Airport (MSP)- Allina Health EMS o Rochester International Airport (RST)- Gold Cross EMS  EMS personnel are trained to screen patients on site if their symptoms are congruent with EVD or other HCIDs. If an EMS crew arrives on scene and suspects EVD or another HCID, and they are not capable to transport, they will activate the

39 If for any reason these services cannot perform the transfer, another pre-identified “Ebola/HCID Ready” ambulance service will be utilized. 49

appropriate “Ebola/HCID Ready” ambulance service to transport the patient to the appropriate hospital. 5. Transport- Accepting Regional Transport from Out of State at Region V RTC:  AIR TRANSPORT: o Preferred mode of transportation from a hospital over 200 miles away within HHS Region V o Designated Airports: Downtown Saint Paul Airport (STP) Holman Field, Minneapolis-Saint Paul International Airport (MSP), Rochester International Airport (RST)  GROUND TRANSPORT: o This is the preferred mode of transportation from a hospital within 200 miles of UMMC-West Bank. It is noted most of western Wisconsin falls into this category. o MDH will take lead and work with other involved HHS Region V health departments, as well as the HHS Region V REC and HPP Project Officer to confirm the logistics and details of ground transport to the Region V RTC in Minneapolis. Items to be addressed prior to the initiation of ground transport include, but are not limited to: 1. Route  Patient Transfer Points (PTPs)  EMS agencies and their leg of journey 2. Communications while in route 3. Contingencies 6. Hospital System:  Minnesota has two Ebola Assessment Hospitals (AHs) and two state Ebola Treatment Centers (ETCs). Together, these four hospitals are known as the Minnesota Ebola Collaborative Hospitals. One state ETC—the University of Minnesota Medical Center-West Bank—is also the designated U.S. HHS Region V Regional Treatment Center.  Assessment Hospitals-(2) o Children’s Hospitals and Clinics of Minnesota, St. Paul Campus—St. Paul, MN o Allina Health’s Unity Hospital—Fridley, MN  State Ebola Treatment Centers-(2) o Mayo Clinical Hospital, Rochester/Saint Mary’s Campus—Rochester, MN o University of Minnesota Medical Center, West Bank Campus—Minneapolis, MN  Regional Treatment Center-(1) o University of Minnesota Medical Center, West Bank Campus—Minneapolis, MN

7. Waste Management:  The Region V RTC has installed an autoclave in the Ebola and Special Pathogens Unit located at UMMC-West Bank in Minneapolis, MN.  Each AH, ETC, and Region V RTC are able to manage waste for EMS. All AHs and ETCs have contracts with waste management companies to dispose of Category A waste.  Gross decontamination of each ambulance must occur at the accepting hospital as well as per state law, waste be left at the hospital. Disinfectant and other cleaning materials will be provided to EMS for decontamination, however, EMS personnel are responsible for performing the decontamination of the transport vehicle according to their agency SOPs. 8. Fatality Management:  Minnesota EMS agencies will not transport a patient who is dead upon their arrival.  If a patient were to die during an HHS Region V ground transport: o Out of State: a. MDH will defer to the state where the death occurred. b. Per Minnesota Statute 149A.93, if a death occurs outside of the state permits for burial, disposition, or removal are required to transport the body through Minnesota.40 o In-State: a. The EMS agency should proceed to UMMC and upon arrival report to the designated garage. Security will be stationed outside and the doors closed prior to ambulance doors being opened. If not already done by the EMS medical director or online medical control, a UMMC physician in appropriate PPE will declare time of death. Appropriate UMMC staff will notify the Hennepin County Medical Examiner’s (HCME) office of the death, as well as Metro First Call and the Cremation Society of Minnesota. UMMC staff will follow the appropriate CDC Guidelines regarding the bagging of the remains,41 and with EMS crew member assistance, bag the body in the ambulance garage. b. Upon arrival to UMMC, Metro First Call will report to the ambulance garage and load the body into their vehicle to be transported for cremation. After Metro First has departed, the EMS crew will decontaminate their ambulance per protocol and UMMC will gather all Category A waste and properly dispose of it.  If a patient being treated at the RTC were to die, Minnesota will follow CDC guidance to prepare the patient and coordinate with CDC EOC for transport back to their home state for burial.42

40 Minnesota Statute, §149A.93, “Transportation of Dead Human Bodies,” 2016, https://www.revisor.mn.gov/statutes/?id=149A.93 41 “Guidance for Safe Handling of Human Remains of Ebola Patients in U.S. Hospitals and Mortuaries,” CDC, updated February 11, 2015, accessed April 11, 2016, http://www.cdc.gov/vhf/ebola/health care-us/hospitals/handling-human- remains.html 42 Ibid. 51

9. Laboratory:  The Minnesota Department of Health’s Public Health Lab has the ability to test and confirm EVD virus without needing to send to CDC Lab in Atlanta, Georgia.

F. Ohio (as of December 1, 2016) 1. Authorized Public Health and Health Care Coordinating Agency: Ohio Department of Health (ODH) 2. Primary Point of Contact: Chief, Office of Health Preparedness, 614-381-2037/Hospital Preparedness Coordinator, 614-254-4774 3. Active Monitoring/Direct Active Monitoring:  ODH has previously developed a protocol and infrastructure to conduct monitoring in coordination with local health departments. Monitoring protocols and resources will be adapted per CDC guidelines and situation specific recommendations.  Monitoring will take place for 21 days past the last possible exposure to Ebola and can occur on a voluntary basis or may be required by public health order (depending on the risk status of the traveler).  Individuals who do not comply with monitoring are subject to: possible legal action including quarantine, isolation, Do Not Board orders (restricting ability to fly), or other restrictions on their movement or activities. Non-compliant individuals will be handled on a case-by-case basis.  Active Monitoring o Individuals being monitored must take their temperature twice daily, watch themselves for symptoms, and immediately tell public health officials if they have a fever or other symptoms. o Public health officials are responsible for checking at least once a day to see if individuals have a fever or other symptoms of Ebola.  Direct Active Monitoring o Public health officials conduct monitoring by directly observing the person. This means that a public health official directly observes the person at least once a day to review symptoms and check their temperature. o Direct observation can be through electronic means (Skype, Facetime). A second follow-up per day can be done by telephone instead of being directly observed. 4. EMS:  Ohio has eight identified EMS agencies capable of transferring EVD/HCID patients.  In the event ODH is required to coordinate transport of EVD patients or PUIs to the most appropriate level of care or an airport, EMS transport companies have been identified.  LHD and Regional Coordinators will coordinate EMS activities and PUI transport to a hospital.  Hospitals will coordinate EMS activities and inter-hospital patient transfer.

5. Transport from Ohio to the Region V RTC:  ODH, Regional Coordinators, LHDs, and hospitals will coordinate and support all EMS activities related to medical evaluation, patient care, and transportation.  AIR TRANSPORT: o Preferred mode of transportation from a hospital in Ohio to the University of Minnesota Medical Center o Designated Airport(s): Cleveland-Hopkins International Airport, Cincinnati/Northern Kentucky International Airport, Port Columbus International Airport, Rickenbacker International Airport o ODH will assist coordination of EMS ground transport from the hospital to the airport in the event an EVD patient is flown to the Region V RTC at UMMC-West Bank.  GROUND TRANSPORT: o ODH will work with the Minnesota Department of Health and other involved HHS Region V health departments, as well as the HHS Region V REC and HPP Project Officer to confirm the logistics and details of ground transport to the Region V RTC in Minneapolis. Items to be addressed prior to the initiation of ground transport include, but are not limited to: 1. Route  Patient Transfer Points (PTPs)  EMS agencies and their leg of journey 2. Communications while in route 3. Contingencies 6. Hospital System:  Ohio follows the EVD-tiered response with all hospitals considered as Frontline Health Care Facilities.  Assessment Hospitals-(7) o St. Rita’s Medical Center—Lima, OH o Nationwide Children’s Hospital—Columbus, OH o The Ohio State University Wexner Medical Center—Columbus, OH o University of Cincinnati Medical Center—Cincinnati, OH o Cincinnati Children’s Hospital Medical Center—Cincinnati, OH o Good Samaritan Hospital—Cincinnati, OH o The Christ Hospital—Cincinnati, OH  State Ebola Treatment Centers-(1) o Metro Health Medical Center—Cleveland, OH 7. Waste Management:  ODH will exercise the guidance provided by the CDC in addition to the medical or infectious waste rules and regulations established by law to ensure waste is managed.  Each EMS/transport entity is required to have a waste management plan and follow their protocol so all waste is safely and properly disposed.  Receiving hospitals will assist EMS when needed in the disposal of Category A waste.

8. Fatality Management:  A confirmed case or PUI dying while being transported to an Assessment Hospital will be transported to the nearest Assessment Hospital and the appropriate fatality protocols will be followed by the Assessment Hospital.  A confirmed case or PUI dying while being transported to an airport will be transported to the nearest Assessment Hospital and the appropriate fatality protocols will be followed by the Assessment Hospital. 9. Laboratory:  ODH Public Health Laboratory is able to test specimens for EVD using the Ebola Zaire (Target 1) Real-Time – Polymerase Chain Reaction (RT-PCR) Assay.  CDC Emergency Operations Center will be consulted if necessary by ODH.  ODH Laboratory takes 4-6 hours for presumptive tests once received. If presumptive negative, hospitals will need to resubmit the specimen in 72 hours. If then presumptive positive by ODH Lab, specimen will be sent to CDC for definitive testing which should be available 6 to 8 hours after CDC receives the specimen.

G. Wisconsin (as of December 1, 2016) 1. Authorized Public Health and Health Care Coordinating Agency: Wisconsin Division of Public Health (WI DPH) 2. Primary Point of Contact: 24/7 Infectious Disease On-Call number at 608-258-0099 3. Active Monitoring/Direct Active Monitoring:  In the event the monitoring would need to be implemented, a detailed protocol maintained by WI DPH Bureau of Communicable Diseases would be used. This protocol can be found at: https://www.dhs.wisconsin.gov/publications/p0/p00903.pdf. 4. EMS:  As of June 3, 2016, there are eight (8) designated EMS providers throughout Wisconsin capable of transporting a patient with known or suspected Ebola.  Activation occurs through WI DPH, Bureau of Communicable Disease.  Upon activation by WI DPH, EMS will transport a patient to one of the five (5) designated Ebola assessment hospitals or one of the three (3) treatment hospital within the state. 5. Transport from Wisconsin to the Region V RTC:  AIR TRANSPORT: o Preferred mode of transportation from a hospital over 200 miles away from the University of Minnesota Medical Center, including major metropolitan areas of Madison and Milwaukee o Designated Airport(s): Dane County Regional-Truax Field (KMSN); Waukesha County Airport (KUES) o WI DPH will assist coordination of EMS ground transport from the hospital to the airport in the event an EVD patient is flown to the Region V RTC at UMMC-West Bank.  GROUND TRANSPORT: o It is noted most of western Wisconsin falls into this category due to its proximity (less than 200 miles) to the RTC in Minneapolis, MN. o WI DPH will work with the Minnesota Department of Health and other involved HHS Region V health departments, as well as the HHS Region V REC and HPP Project Officer to confirm the logistics and details of ground transport to the Region V RTC in Minneapolis. Items to be addressed prior to the initiation of ground transport include, but are not limited to: 1. Route  Patient Transfer Points (PTPs)  EMS agencies and their leg of journey 2. Communications while in route 3. Contingencies

6. Hospital System:  Wisconsin has a 3-category (tier) hospital system. Every facility has capability to identify and transfer to an assessment hospital (Category 2). If confirmed case, the patient is transferred to a treatment center (Category 1) or UMMC-West Bank in Minnesota, depending on patient point of origin (see first bullet of “Transport” above).  Assessment Hospitals-(4) o St. Joseph's Hospital—West Bend, WI o St. Mary's Hospital—Madison, WI o Gundersen Lutheran Hospital—La Crosse, WI o Sacred Heart Hospital—Eau Claire, WI  State Ebola Treatment Centers-(3) o Children's Hospital of Wisconsin—Milwaukee, WI o Froedtert & the Medical College of Wisconsin—Milwaukee, WI o UW Health University of Wisconsin Hospital and the American Family Children's Hospital—Madison, WI 7. Waste Management:  Waste produced during the course of patient transport will be managed by the receiving assessment or treatment facility (PTPs). All assessment and treatment facilities in Wisconsin have Category A vendors in place to dispose of waste in accordance with state and federal regulations. 8. Fatality Management:  There are no protocols in place for management of fatalities by EMS agencies. We anticipate that remains will be properly handled by the staff of the receiving assessment or treatment facility.  State Statute 157.055 Disposal of human remains during state of emergency relating to public health, allows the state to take control of any human remains to dispose of them properly. 9. Laboratory:  The Wisconsin State Laboratory of Hygiene (WSLH) provides EVD and malaria testing for PUIs. All positive samples are forwarded to the CDC for further analysis.  WI DPH and WSLH consult with assessment and treatment hospitals on additional diagnostic testing for patients being evaluated for Ebola. Specialized viral testing can be performed at WSLH if needed in a rule-out scenario.  WSLH provides consultation to the assessment and treatment hospitals for packaging, transporting, and shipping of EVD specimens to the state lab.

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Appendix C: Initial Notification Flowchart43

43 This is initial notification of transfer of a confirmed Ebola/HCID patient to the RTC. For additional notification and communication processes, please reference your jurisdiction’s ConOps. 59

Appendix D: Ebola Patient Decision Algorithm44 This algorithm outlines where confirmed cases of EVD will seek treatment in the United States. It utilizes the tiered hospital approach of the Regional Treatment Network (See Appendix H: Definition of Terms). Patient placement and transfer decisions are dependent on clinical circumstances, available logistical resources, patient preferences, and in consultation with relevant local, state, regional, and federal public health authorities.

For this Plan, this patient algorithm will be used as guidance on a case-by-case basis. As the Regional Treatment Network expands, transfers to a different jurisdiction (city/state) within HHS Region V and outside HHS Region V may become less frequent.

44 “Funding Opportunity Announcement: Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities CFDA #93.817,” U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response, 2015, p 34-35.

Appendix E: Inter-Regional Transfer The likelihood of a transfer from a different region is low as they are more likely transfer a confirmed Ebola patient to their respective RTCs. However, in the event CDC recommends a patient be transferred to Region V RTC from a different region, MDH will coordinate with ASPR, CDC, local, tribal, and state health departments, medical facilities, EMS, police, and air transport as appropriate to facilitate the transport. The proximity of the Region V RTC to states in Regions VII (Iowa) and VIII (North Dakota, South Dakota) is close and therefore the Region V RTC and MDH is willing to work closely with colleagues in those regions to provide care to patients if needed. Distance from HHS Region VII and VIII ETCs to the Region V RTC:  Iowa o University of Iowa Hospitals and Clinics—Iowa City, IA . 4 ½ hours (303 miles)  North Dakota o Sanford Health Medical Center—Fargo, ND . 3 ½ hours (236 miles)  South Dakota o Sanford USD Medical Center—Sioux Falls, SD . 4 hours (240 miles)

There is also the possibility a jurisdiction within HHS Region V would transfer a confirmed case of EVD to another RTC. Most notably, the jurisdiction of Ohio’s ETC, MetroHealth Medical Center located in Cleveland, Ohio is closer to the HHS Region III RTC located at Johns Hopkins Hospital in Baltimore, Maryland (375 miles compared to 750 miles). If a ground transport is the only option, it is conceivable HHS Region V would reach out to colleagues in HHS Region III to accept the patient for additional treatment. HHS Region V will coordinate with ASPR, CDC, local, tribal, and state health departments, medical facilities, EMS, police, and air transport as appropriate to facilitate the transport.

Appendix F: List of Region V Ground Transport Patient Transfer Points

If PAG fixed-wing air ambulance is unavailable for a variety of reasons—weather, aircraft, and crew availability—a contingency ground transport plan must be in place. Regional ground transport will be based on each jurisdiction’s respective ConOps. Pre-identified EMS agencies will be used within each jurisdiction with pre-identified patient transfer points (PTPs) located at AHs or ETCs spread throughout HHS Region V (See section 3.5 for more detail).

Starting Point or Destination Hospital Approximate State City Mileage Patient Transfer Point City, State Time45  ProMedica Monroe Regional 131 2h 5min Ohio Cleveland  MetroHealth Medical Center Hospital—Monroe, MI  Sturgis Hospital—Sturgis, MI 210 3h 15min  ProMedica Monroe Regional Monroe  Sturgis Hospital—Sturgis, MI 137 2h 15min Hospital  Detroit Receiving & Detroit University Health Center  Sturgis Hospital—Sturgis, MI 160 2h 40min Michigan  Henry Ford Hospital46 Chicago ETCs or CERN Hospitals Sturgis  Sturgis Hospital 140 2h 35min (see below)47  UP Health System—  HSHS Sacred Heart Marquette 310 5h 30min48 Marquette General Hospital Hospital—Eau Claire, WI Indiana (To Be Determined)

45 Approximate times do not include time it would take EMS to safely don and doff PPE. Thirty (30) minutes for each action (total 60 minutes) is considered a reasonable estimate to complete this process. 46 Coordination will be handled by MDHHS. 47 Coordination will be handled by CDPH. 48 If this occurs, Michigan and Wisconsin will work together to find a suitable location for the EMS crew to rest or switch. 62

Starting Point or Approximate State City Destination Hospital Mileage Patient Transfer Point Time49 Chicago ETCs or CERN Hospitals Urbana  Carle Foundation Hospital 139 2h 10min (see below)50 ETCs or CERN Hospitals:  Rockford Memorial 96 2h 20min  Ann & Robert H. Lurie Hospital—Rockford, IL Children’s Hospital of Chicago Chicago  Froedtert & the Medical  Northwestern Memorial College of Wisconsin— 92 2h 5min Illinois Hospital Milwaukee, WI  Rush University Medical Center51  UW Health University of Wisconsin Hospital and the Rockford  Rockford Memorial Hospital 74 1h 25min American Family Children’s Hospital—Madison, WI  UW Health University of  Froedtert & the Medical Wisconsin Hospital and the Milwaukee 76 1h 25min College of Wisconsin American Family Children’s Hospital—Madison, WI  UW Health University of  Gundersen Lutheran 146 2h 30min Wisconsin Hospital and the Hospital—LaCrosse, WI Madison American Family Children’s  HSH Sacred Heart Hospital— Wisconsin 182 2h 50min Hospital Eau Claire, WI  Gundersen Lutheran  Mayo Clinic St Marys La Crosse 74 1h 15min Hospital Campus—Rochester, MN Regional Treatment Center: Eau Claire  HSHS Sacred Heart Hospital  UMMC—West Bank— 91 1h 30min Minneapolis, MN Regional Treatment Center:  Mayo Clinic St Marys Rochester  UMMC—West Bank— 85 1h 20min Minnesota Campus Minneapolis, MN

49 Approximate times do not include time it would take EMS to safely don and doff PPE. Thirty (30) minutes for each action (total 60 minutes) is considered a reasonable estimate to complete this process. 50 Coordination will be handled by CDPH. 51 Coordination will be handled by CDPH. 63

Appendix G: Map of Region V Ground Transport Patient Transfer Points

Appendix H: Definition of Terms Concept of Operations (ConOps) A conceptual overview of the processes and steps envisioned in the proper functioning of a system or in the proper execution of an operation. This overview also can include responsibilities and authorities, available resources, and methods to improve communications and coordination. Doffing The process of removing used personal protective equipment. Donning The process of putting on clean personal protective equipment Ebola virus disease (EVD) Previously known as Ebola hemorrhagic fever.

A rare and deadly disease caused by infection with one of the Ebola virus strains. Ebola can cause disease in humans and nonhuman primates (monkeys, gorillas, and chimpanzees). High Consequence Infectious Disease (HCID) A broad range of pathogens that have the potential to disrupt normal operations, involve additional non-routine measure to care for patients, involve special considerations for staff safety or waste management.

HCIDs that may require transfer to the RTC include infection with a pathogen that meets either of the following criteria:

1. Pathogens for which all forms of medical waste (including patient excreta, secreta, blood, tissue, tissue swabs, and specimens in transport media) are classified as Category A infectious substances (UN2814) by the U.S. Department of Transportation;

2. A pathogen with the potential to cause a high mortality rate among otherwise non- critically ill immunocompetent people for which no routine vaccine exists and has one or both of the following characteristics: a. At least some types of direct clinical specimens pose generalized risks to laboratory personnel b. Known risk of secondary airborne spread within health care settings or unknown mode of transmission

Jurisdiction For the purposes of this Plan, “jurisdiction” refers to the City of Chicago or one of the six states within the geographic boundaries of HHS Region V. They are: Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin. Patient Transfer Point (PTP) Patent Transfer Points are utilized during the ground transfer of a patient from one hospital to another. PTPs are utilized in both jurisdiction ConOps as well as regional plans. Throughout HHS Region V, PTPs are pre-identified Assessment Hospitals (AHs) or Ebola Treatment Centers (ETCs). Person Under Investigation (PUI) A person who has both consistent signs or symptoms and risk factors as follows should be considered a PUI for the Ebola virus disease:

▪ Elevated body temperature or subjective fever or symptoms, including severe headache, fatigue, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage AND

▪ An epidemiologic risk (http://www.cdc.gov/vhf/ebola/healthcare-us/evaluating- patients/faqs-screening-ebola-providers-hc-facilities-health-departments.html) factor within the 21 days before the onset of symptoms Regional Treatment Network for Ebola and other HCIDs in the United States52,53 To create a coordinated networked approach, state and local health officials, in collaboration with hospital and health care facility executives, may designate health care facilities across the country to serve in one of three suggested roles outlined in this guidance document. ▪ Regional Treatment Centers (RTCs) ▪ Ten facilities, one located in each HHS region, throughout the U.S. ▪ Agree to serve as regional assets and agree to accept patients from outside of their region. ▪ Maintain enhanced capacity to care for Ebola/HCID patients for the duration of illness in addition to all requirements of an Ebola Treatment Center. ▪ State Ebola Treatment Centers (ETCs) ▪ Identify, isolate, and conduct all testing for patients with relevant exposure history and symptoms. ▪ Care for and manage patient for the duration of illness. ▪ Notify appropriate public health authorities. ▪ Maintain Ebola PPE sufficient for at least 7 days of patient care.

52 http://www.cdc.gov/vhf/ebola/healthcare-us/preparing/hospitals.html 53 “Funding Opportunity Announcement: Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities CFDA #93.817,” U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response, 2015.

▪ Assessment Hospitals (AHs) ▪ Identify and isolate patients with relevant exposure history and symptoms. ▪ Notify appropriate public health authorities. ▪ Staff trained and proficient in donning/doffing, proper waste management, infection control practices and specimen transport. ▪ Maintain Ebola PPE sufficient for 96 hours of patient care. ▪ Transport to treatment center if confirmatory test is positive. ▪ Frontline Hospitals ▪ Identify and isolate patients with relevant exposure history and symptoms. ▪ Notify appropriate public health authorities. ▪ Staff trained on specimen transport, waste management, Standard Precautions; proficient in donning/doffing PPE. ▪ Maintain access to Ebola PPE sufficient for 12-24 hours of patient care. ▪ Transport to assessment hospital or treatment center for additional testing and care.

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Appendix I: Notification Checklist with Important Phone Numbers

Once the decision has been made to transfer a confirmed patient to the RTC located at UMMC-West Bank in Minneapolis, MN, please activate the Plan using the appropriate initial notification process. For additional notification and communication processes, please reference your jurisdiction’s ConOps and the GLHP Alerting and Communications Annex.

Notification Phone Number Notified By (Employee Name) Date Time

☐ Minnesota Department of Health 651-201-5735

(cell) 202-329-7205 ☐ HHS Region V HPP Project Officer: CDR Duane Wagner (office) 312-886-0693 (cell) 312-718-0388 ☐ HHS Region V REC: CAPT Janet Odom (office) 312-886-0696

☐ Airport A (Sending Airport): ______

If Applicable Notification

☐ HHS Secretary’s Operations Center54 202-619-7800

☐ CDC Quarantine Station55,56,57 See Below

☐ CDC Emergency Operations Center58 770-488-7100

54 If unable to repeatedly reach the HHS Region V REC, the affected jurisdiction’s health department should contact the HHS SOC directly. 55 Michigan and Ohio-Detroit CDC Quarantine Station: 773-894-2960 56 Indiana, Illinois, City of Chicago, and Wisconsin-Chicago CDC Quarantine Station: 734-955-6197 57 Minnesota-Minneapolis-St. Paul CDC Quarantine Station: 612-725-3005 58 Should a patient die during transport and the body needs to cross state lines, please coordinate with the CDC EOC.