PANX 2018 EXECUTIVE LEVEL PANDEMIC RESPONSE WORKSHOP
EXECUTIVE LEVEL BRIEFING
PanX 2018 was an executive-level workshop hosted by NYC Health + Hospitals
(H+H), the nation’s largest municipal healthcare delivery system, in
collaboration with the Johns Hopkins University Center for Health Security. The
workshop was held in November 2018 to mark the 100th anniversary of the
1918 influenza pandemic. The principal aim was to highlight important highlevel strategic decisions an integrated healthcare delivery system—comprising
acute, post-acute, and ambulatory sites—would pursue along with local, state,
and federal public health authorities in order to prepare for and respond to a
severe pandemic. The pandemic scenario was presented through series of
simulated Emergency Operations Center (EOC) incident briefings with 18
senior leaders across H+H’s healthcare delivery system playing in their current,
prominent roles and representing all aspects of healthcare delivery from clinical care operations to
laboratory, finance, human resource, and others across the three service lines. Module 1 of the workshop
focused on the healthcare delivery impact and initial response to an
unfolding pandemic. Module 2 focused on the role of public health partners
and liaisons in supporting the healthcare delivery system. Participant roles
included nine local, state, and federal healthcare and public health officials,
played by individuals in current, prominent fields of public health or
epidemic response. Module 3 addressed some preparedness and response
challenges related to surveillance and diagnostic technology as experts
described many new innovative tools that may be implemented for future
use.
Module 1 Exercise Players

EXERCISE FORMAT
PanX 2018 was conducted in front of a live audience of more than 100 healthcare executives, senior
advisors, academics, and government officials as well as national and international public health
community members. The exercise was organized into three modules. Information was provided to the
players via emergency operations briefings and pre-produced media video clips.
Module 1: Healthcare Delivery Impact & Response
Module 1 addressed issues associated with impact to the healthcare
delivery system—specifically, in the context of facility staff, supplies, and
space—during an unfolding novel H7N9 influenza epidemic in NYC. Module
1 included high-level lessons learned from a real infectious disease mystery
patient surge drill conducted previously at a NYC Health + Hospitals acute
care site.
Module 2: Public Health Partners & Liaisons
Module 2 explored the public health response to an unfolding epidemic in
NYC, including the assistance and resource support provided to healthcare
delivery systems like NYC Health + Hospitals. Playing agencies included:
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New York City Department of Health and Mental Hygiene
New York City Emergency Management
New York City Fire Department Emergency Medical Services
Greater New York Hospital Association
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Surge Mystery Patient Drill
NYC Health + Hospitals/Elmhurst

Office of the Assistant Secretary for
Preparedness and Response
Centers for Disease Control and Prevention
National Ebola Training and Education Center

 Module 3: Current and Prospective Technologies for Pandemic Preparedness and Response
Module 3 consisted of presentations from the Originator of “Outbreaks: Epidemics in a Connected World”
by Smithsonian Institute National Museum of National History on lessons learned from 1918, Defense
Advanced Research Projects Agency (DARPA) of the United States Department of Defense, CDC and
Johns Hopkins Center for Health Security on innovative technologies that could support pandemic
preparedness now and in the future.

EXERCISE SCENARIO
The PanX 2018 scenario begins with Module 1, and players are presented
with the following information: The National Health and Family Planning
Commission of China notifying the World Health Organization (WHO) of
laboratory-confirmed cases of human infection with avian influenza H7N9
virus with investigation ongoing. There have been no cases reported outside
of China. The first discussion in Module 1 focused on what, if anything, NYC
Health + Hospitals would do in response a distant outbreak of H7N9,
including what effect these actions might have on routine operations.
Dr. Kevin Yeskey, Principal Deputy, ASPR,
Keynote
, Keyno

As the scenario continues, several EOC Incident Briefings were convened
with Executive Leadership to provide system updates and current events as
novel H7N9 with human-to-human transmission spreads outside of China and into NYC, initially undetected
against the background of early flu season cases, resulting in several generations of disease transmission.
Additional context was presented to the participants to illustrate the projected severity of the outbreak on
the healthcare delivery system. Staffing models demonstrated the increased patient influx and the
associated burden on staff. The projected epidemic curve showed that the surge was expected to escalate
further as time progressed.

Throughout the ongoing discussion in Module 1, Executive Leadership deliberated necessary response
actions as they were confronted with several complex problems, including:
 Threat of a distant outbreak
 Surge capacity of healthcare delivery system
 Depleting supply stockpile and concerns over resource
allocation
 Staffing shortages and disproportionate staff to increased
patient ratio
 Additional space needed for increased patient volume surge
 Command, control and communications within the healthcare
delivery system
 Communication, collaboration
Pre-Produced News Clipping #2
NYC Health + Hospitals/Jacobi
 Crisis standards of care
Module 2 centers on the public health response occurring in the same timeframe presented in Module 1.
The discussions focused on the role, the type of assistance, and resource support each participating
agency would be providing to H+H and other healthcare delivery systems as the pandemic emerges in New
York City as well as their respective triggers points for activating internal response mechanisms.

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 RECOMMENDATIONS
PanX 2018 was based on the principle that, ready or not, patients will present. The frontlines of healthcare
delivery span the acute, post-acute, ambulatory facilities and all other sites that deliver healthcare services.
To better prepare for and respond to future epidemics, NYC Health + Hospitals recommends 4 strategic
priorities:
1. Strong Focus on the Frontlines of Healthcare Delivery: Decision Support Tools, Diagnostic
Resources, and Training
a. Enhance Tools and Resources at the Frontlines of Healthcare Delivery
i. Improve local disease screening surveillance and decision support
1. Enhance electronic medical records to facilitate routine travel & illness
screening
2. Real-time data analytics of patient arrivals at healthcare facilities for
outbreak detection and reporting
3. Surveillance results shared with public health entities in real-time to allow
greater sensitivity to pandemic situations
ii. Establish regional and national databases to track trends; suspected cases,
outbreaks, survivors and other relevant data for agencies and healthcare entities.
1. This data can be used to tailor response and interventions
2. Use of cell phones and internet to communicate with the public to help
with reporting of signs and symptoms
iii. Optimize ability to upscale clinical evaluation capacity and diagnostic capabilities
1. Design & simulate robust surge plans in anticipation of need to expand
clinical care delivery space (e.g. tents, trailers, re-opening closed “brick
and mortar” clinical units) to increase throughput
2. Rapid lab turn-around time for routine use that can be scaled upward
during enhanced volume (e.g. increase quantitative PCR analyzers
available) and optimizing use of point-of-care diagnostic testing
3. Stockpile therapies for rapid distribution and develop plans to increase
manufacturing during a pandemic
b. Increase Available Training for Frontline Staff
i. Help frontline staff prepare to manage atypical tasks for their positions during
critical need. Design just-in-time, adaptability and, cross training including:
1. Basic ventilator use, medication pumps, pressure bag implementation and
equipment troubleshooting for non-ICU staff
2. Non-specialty physician, nurse practitioner & physician assistants training
in life saving procedures (e.g. endotracheal intubation, cricothyroidotomy,
needle decompression, etc.)
ii. Increase training center capabilities for both ongoing as well as upscaling for justin-time training
1. Regional training centers need to be developed to train key staff at health
systems who will conduct the ongoing and just-in-time training
2. Up-to-date national database of reserve corps of volunteers and trained
personnel with uniform credentialing guidelines

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 2. Interdisciplinary Network: A ‘Brain Bank’ to Provide Guidance to Healthcare Delivery
System and Answer Questions Regarding Clinical Care Protocols in Real Time
a. Establish a multidisciplinary group of subject matter experts to engage in in-depth dialogue
regarding crisis standards of care and proactive methods for managing the impact to the
healthcare delivery system during an outbreak
i.
These experts would represent various backgrounds, such as physicians, nurses,
infection preventionists, public health professionals, ancillary support staff
professionals, and epidemiologists, etc. in order to foster a multifactorial approach.
This group would create and communicate changes in/deviations from usual
practice standards as a result of waivers to regulations issued in a pandemic; e.g.
changes in Emergency Department triage protocols
b. Develop networks of experienced professionals equipped to answer questions and provide
methodological advice using best information available
i.
The ‘Brain Bank’ would serve as a clearinghouse for frontline providers’ questions
and operational concerns and link to an external network of experts who could
offer additional intelligence and highly specialized expert advisors
c. Create a sector of the interdisciplinary team specifically responsible for guidance of
Intensive Care Unit interventions in a crisis environment
i.
The team’s suggested interventions and guidance to support crisis standards of
care would grant temporary permission to thoughtfully improvise during the event
of a pandemic
1. The short-term solutions may involve temporary waivers and regulatory
by-passes. Protocols related to these solutions would be formed and may
be based upon best practices and predicted surge incidents
a. For example, developing guidelines for using a single ventilator
for ventilating multiple patients simultaneously and for timing of
triage out of the ICU when recovery chances are decreasing, may
facilitate maximizing the number of individuals treated
2. Successful interventions developed through this collaboration would then
be communicated across the health system and to external partners for
potential implementation
3. Consistent and Reliable Communication, Coordination, and Collaboration between Public
Health Agencies and Healthcare Delivery Systems via Emergency Management Structures
and Processes
a. Communication: Develop and implement functional plans for public communication of a
unified and coordinated message for local, state, national and international partners
including the United Nations (UN), CDC, ASPR, NYC DOHMH, World Health Organization
(WHO) to ensure transparent information sharing
i. Guidance from various public health and federal agencies should be consistent
and in agreement with one another
1. Clinicians often rely upon these official guidance announcements,
especially during emergencies. A unified message is key to promoting a
standardized approach to clinical practices across multiple healthcare
systems
2. This guidance includes elements such as accurate case definitions (e.g.,
incubation period, symptomology, exposure), managing ill staff, and
vaccine protocols and standards
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 ii. Create a more efficient and streamlined reporting system to avoid repetitive
information sharing
1. Multiple public health and federal agencies request overlapping
information from healthcare facilities, which poses increased burden on
limited resources
2. Hospitals should be responsible for providing an all-inclusive status report
that may be shared amongst the various agencies in order to avoid
repetition and to make more efficient use of their time
b. Coordination: Develop and implement qualitative and quantitative triggers to access public
health and emergency management resources at the local, state, and national levels to
support healthcare delivery systems
i. Public health agencies should work collaboratively with healthcare workers to
develop a sequential process for requesting, accessing, and distributing public
health resources during an epidemic
1. This sequential process should be based upon definitive quantitative
values that identify various levels of event severity based on the hospital’s
current capacity and needs
2. Establish explicit thresholds within this system, including indications of
shortages in any of the following: staff, supplies, and space
a. Permission to overrule certain regulations regarding additional
temporary space should be considered based upon real-time
impact level
i. This includes the authority granted to construct
supplementary space needs in the form of a tent or
mobile medical unit without awaiting regulatory site visit
to operationalize
c. Employ the Incident Command System to manage all activities related to pandemic
response and recovery
i. Establish formal relationships between facility, system, and local/state Incident
Commands to facilitate rapid and effective coordination during pandemic
responses
d. Collaboration: Ongoing collaboration with the health community, effective information
sharing, and coordination of response activities in preparing for and responding to a
pandemic
i. Increase engagement with public health authorities to promote a rapid response to
lessen the burden on a healthcare delivery system prior to and during surge
4. Financial Assistance to Healthcare Delivery Systems to Prepare for, Respond to, and
Recover from a Pandemic
a. Emergency financial aid should be granted to healthcare delivery systems who are
severely affected by a pandemic
i. Financing workers compensation to allow additional sick time/disability allotments
for those health care workers who become ill as a direct result of their care
delivery during the pandemic
ii. Demobilization costs may be substantial, including terminal cleanings,
decommissioning temporary clinical surge care areas, restocking depleted
supplies and accounting for lost/deferred revenues, e.g. due to
canceled/postponed elective procedures

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 CONTACT INFORMATION
If you are interested in learning more about PanX 2018 and the recommendations listed in this document,
contact Dr. Syra Madad at Syra.Madad@nychhc.org or 212-323-2521.

ACKNOWLEDGEMENTS
This executive-level briefing has been developed by:
Dr. Syra Madad, Senior Director, System-wide Special Pathogens Program NYC Health + Hospitals
Julia Stoneham, Intern, System-wide Special Pathogens Program NYC Health + Hospitals
Dr. Laura Iavicoli, Associate Director, Department of Emergency Medicine, NYC Health +
Hospitals/Elmhurst
Dr. Nicholas Cagliuso, Senior Assistant Vice President, Emergency Management
Dr. Sean Studer, Chief of Medicine, NYC Health + Hospitals/Kings County
Dr. Joshua Moskovitz, Associate Director, Department of Emergency Medicine, NYC Health +
Hospitals/Jacobi
Matthew P. Shearer, Senior Analyst, Johns Hopkins Center for Health Security

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 EXERCISE PLAYERS FOR PANX 2018
Module 1: Healthcare Delivery Impact & Response
Player
Paul Albertson
Dr. Machelle Allen
Dr. Nicholas Cagliuso
Andrea Cohen
Victor Cohen
William Foley
Kenra Ford
Dr. Morris Gagliardi
Carey Hamblin
Dr. Khoi Luong
Dr. Theodore Long
Monefa Anderson
Ana Marengo
Dr. Joseph Masci
Maureen McClusky
John Ulberg
Yvette Villanueva
Dr. Eric Wei
Facilitators:

Role
 Vice President, Supply Chain
 System Chief Medical Officer, Senior Vice President, Medical & Professional Affairs
 Senior Assistant Vice President, Emergency Management
 General Counsel, Central Office
 Senior Assistant Vice President, Pharmacy
 Senior Vice President, Acute Care Operations
 Chief of Staff, Senior Assistant Vice President, Medical & Professional Affairs & Laboratory
Operations
 Chief Medical Officer, NYC H+H/Gotham & Gouverneur
 Chief Nursing Officer, Ambulatory Care Operations
 Director Medical Affairs, Post-Acute Care Operations
 Vice President, Ambulatory Care
 Chief of Staff, Senior Assistant Vice President, Nursing (delegate for Dr. Mary Ann Marra,
Interim System Chief Nursing Officer)
 Senior Vice President, Communications & Marketing
 Chairman, Global Health Elmhurst Hospital Center
 Senior Vice President, Post-Acute Care Operations
 Senior Vice President, Finance Administration
 Vice President, Human Resources
 Vice President, Quality
Drs. Syra Madad & Joshua Moskovitz

Module 2: Public Health Partners & Liaisons
Player
James Esposito
Dr. Christopher Kratochvil
Kathleen Gaine
Jenna Mandel-Ricci
Dr. Diana Martinez
Dr. David Prezant
Marisa Raphael
Dr. Timothy Uyeki
Dr. Kevin Yeskey
Facilitators:

Role
Deputy Commissioner for Planning & Preparedness, New York City Office of Emergency
Management
Associate Vice Chancellor for Clinical Research, UNMC, Co-PI NETEC
Regional Program Director, New York State Department of Health
Vice President, Regulatory and Professional Affairs, Greater New York Hospital Association
Senior Advisor, Health Policy, City Hall
Chief Medical Officer, Office of Medical Affairs, New York City Fire Department
Deputy Commissioner Office of Emergency Preparedness and Response, New York City
Department of Health and Mental Hygiene
Chief Medical Officer, Influenza Division, CDC
Principal Deputy, Office of the Assistant Secretary for Preparedness and Response
Drs. Syra Madad & Nicholas Cagliuso

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