Point of Distribution Exercise

Overall Action Plan & Model

Adam Kirby, Luke Hohmann, Pamela Aaltonen, & J. Eric Dietz

Purdue University

January 2016
Abstract

Execution of a proper distribution exercise is the only way to ensure successsucceed in

the case of an actual mass prophylaxis event. Without proper training and practice, providing to

the public the necessary product or medication during distribution can cause extreme chaos and

confusion. The planned exercise presented in this study was developed to ensure that all planners

and workers are prepared for an actual event and how to deal with certain scenarios which may

occur.

Introduction

Project and Observations

The following project is an overviews of the planned exercise that was performed. The

exercise took place at the Tippecanoe County Fairgrounds in Lafayette, Indiana. The provided

the proper building size and had adequate amounts of parking and resources. The hog barn was

chosen because it had plenty of room for the exercise to take place. The building allowed for

easy entrance access for all people, including handicapped, and was easy to find. There was more

than enough room for the Point of Distribution (POD) to be set up and people to move around

freely. Approximately one quarter of the space was used for the exercise, which involved a

sample of about 75 people. , soTherefore, there would have easily enough room to process more,

especially if the exercise was running continuously. Plenty of pParking was readily available and

the location was not on a busy road making it even made it better for crowd control and traffic

management.
 Once the exercise was set up, Tthe different stations of the exercise includedd triage,

registration, screening, and distribution in orderthat order. The triage station was there to

evaluateevaluated individuals entering the exercise, to determininge the priority of their

situation. Triage is an extremely important step in the exercise because it can determineregulates

how far the individual has progressed in the given situation. This step can help keep individuals

safer by determining how someone is doing rather than letting them get near everyone and

contaminate thempreventing contamination, or allowif perhaps they require i immediiate medical

attention if they require it. , Tthis identification can be taken care of faster than if they

participated allowing them to participate in the distribution and caused a scene. The next station

was the registration station where individuals filled out information about themselves- including

mostly family information. Once the registration process was finished, the individuals were sent

to screening where they werewould be evaluated based on their information and given the go

aheadpermission to continue. They arrived at the on to the distribution table where they were

allotted their amount of medication.

At the exercise, tThere were different people present from local government agencies and

Purdue University to complete the exercise. The health department was present and used in the

guidance of crowd control and a few members workeding at the triage and registration stations.

Two police officers were present to provideprovided security and assistance. Most of the

individuals working all the stations were seated in pairs and were from either Purdues or Ivy

Techs nursing programs.

The exercise showed many scenarios and emergent phenomena that could be studied.

There were multiple individuals that had complications walking, which caused them to trip and
break their leg or foota bone. This , requirinrequiredg them to be eitheran escorted through in a

wheel chair or evacuationated through in a wheel chair. There was an individualassigned

individual that was playingto play the role of a lost, t and confused, and mute person who could

not speak. That particular individual sat in the registration area for quite some time before being

noticed. There was a sick individual that was throwing up which was intended Tto add a

complicationcomplicate to the exercise, there was an assigned sick individual that vomited.

There was a A hyperventilating individual that was stressed and causing caused a scene; theyat

had to be evacuated. There were Iindividuals that would argueargued with workers at the

dispensing and screening stations. that they were not being treated fairly and that they needed

more medication for a number of reasons including for their loved ones that werent present or

because they believed they just needed more. A final individual was acted as a protester that had

nothing good to say aboutobjected to the exercise or and the medicine being that was dispensed.

They at the exercise arguedarguing that no one knew what it was, that it was a government

scandal, and that no one should take the medication. This led to him beingEventually, he was

forcefully evacuated by the by the police in a forceful manner. These people were all placed at

key locations and timings to create confusion and chaos at inopportune moments for the workers

to test them and see how they would respond to the disruptions.

After the observational phase of the planned exercise, there were many observations

noted that caused this to be a successful exercise and several observations noted that should be

improved upon or done differently. There are many things that need to be taken into account to

have a successful exercise. The Federal Emergency Management Agency or FEMA (FEMA) has

a lists of 31 core capabilities that they use as the distinct critical elements needed to achieve a

goal [1]. In this case, the goal for the exercise was to create a planned distribution exercise and
finish it quickly without many problems to better prepare the workers for an actual event.

Lafayette is not a giant city. However, the 31 core capabilities were still used. The capabilities

could have been used in greater detail to create a stronger exercise with a better outcome.

First and most important on the core capabilities list and most important is planning. As

FEMA describes planning, it is to conduct a systematic process engaging the whole community

as appropriate in the development of executable strategic, operational, and/or community-based

approaches to meet defined objectives. The planning portion of this exercise was executed to a

certain extent but could have been performed better. The triage station is arguably the most

important part of the exercise because it is a failsafe set to eliminate potential problems before

they end up taking place. That being said, theThe triage station was placed in an area that caused

a large percentage of the people passing through to miss it. When someone misses the triage

station, that person that has a problem now people with problems becomes someone elses job

later down the line that may not be trained to deal with that situation or does not have time to

deal with it because they are performing another task that is important. Missing the triage station

can cause cause problems backups in the exercise. throughout the exercise concerning something

as simple as language barriers to someone severely infected with the sickness at hand. When

someone misses the triage station, that person that has a problem now becomes someone elses

job later down the line that may not be trained to deal with that situation or does not have time to

deal with it because they are performing another task that is important. This can also cause

backups in the exercise. When something backs up further down the line, the issue usually comes

from something not working properly or as efficiently in the frontinefficiencies or misuse in the

front. To fix this issue, the triage station needs to should be positioned in an area directly in front

of the registration area. so no one would miss it because it would be the first thing seen when
walking in the door. Moving the location would immediately eliminate the chance of missing it.

Another solution for identifying where to go is toAdditionally, visibly simply numbering the

stations in large, visible areas where everyone can see them would , helping guide the individuals

through the stations.

Besides the triage station, pPlanning needed to be done more effectively in other

situations during the planned exercise. besides the triage station. The serpentine shaped setup of

the exercise created some crowding in areas that and could cause chaos in the heat of the

moment if the exercise had was an actual scenarioactually occurred. The floor space following

the registration area to go to the screening area was creatingcreated a funnel shape for people to

gather in. This funnel shape created an accumulation of people that didnt create a problem in the

exercise but has a great probability in the occurrence of an actual distribution event. When

people feel threatened, individuals will be less inclined to act appropriately. and the idea of A

largea group of people causess some individuals to to end up takingtake more time to get to

reach the next station than those in the front. People are more likely to push forward in hopes of

reaching the front faster. Other thanBeside the being serpentine in shaperoad, the only things

keeping people in line were traffic cones and yellow caution tape kept people in line. However,

aAnyone could push or break through them that over or break through creating unnecessary

chaos and confusion.

Alarmed pPeople who are panicking or wanting to get to the medication will not listen to

the health department workers telling them what to do. It is likely that Iif one person panics and

starts pushingpushes to the front to grab the medicine, many will followothers will follow and

the distribution plan will be lost. A solution is to create a veryA linear and systematic approach
willto move individuals along through the stations making it as single fileindividual as possible;

this and creates ing athe sense of fairness and security to all those participating. Single file is

better than many trying to fight for a spot at the front. The lines need to be designated with

something stronger than caution tape and traffic cones;. seSome sort of separation barriers need

to be established. Along with setting the stations up in a more straightforward way, law

enforcement should be positioned throughout the stations, armed and ready. People are much less

likely to panic and create chaos when they are being told when to continue with law enforcement

nearby.

Another issue with staffing has to do more with theThe locations of the staff members

throughout the exercise stations were problematic. From an observational point of view, there

was much more of a build up at the screening stations where the staff was constantly dealing

with individuals in either arguing with them or simply just an excess amount of

individualsarguments or overflow. This caused some chaos because the screen area determines

what the individuals would receive from the dispensing station. The dispensing station, however,

had twice the amount of staff present with no congestion; and most of the time the staff members

were sitting, not doing anything. Perhaps this is the case because individuals wanting their

medicine only put up a fight at the screening area because they thought that was what they were

meant to do and just gave up on the dispensing area. In a real scenario, individuals could

possibly argue to an extremethe most at the dispensing area because they can see the medicine. A

way to alleviateHaving more the congestion from the exercise would be to have more staff at the

screening area rather than the dispensing areawould alleviate the because that is where most of

the congestion took place.

 Planning needs to be thought through thoroughly thorough, detailed, with the intention to

not miss any small detail and creating contingencycontingent plans for as many scenarios as

possible. Not all of the supplies were readily available. Understanding that several people will

probably not fall and break their limbs, some did in this small-scale exercise. Not all of the

supplies were readily available. The wheel chairs were being used frequently and were needed at

times that they were not accessible because they were already being used by another individual.

Additionally, Some people could get anxiety attacks and pass fainting and an anxiety attacks

could require more wheel cout during an occasion like a distribution when they believe their life

depends on getting the medication. People may need wheel chairs more than normal in this

situation;. Therefore, wheel chairs need to be present and ready for use.

Planning a A distribution exercise is intended to create an example for those that would

be present to get a feel for understand what could take place in the case of an actual event

occurring. Though this event gave a rough idea of that, it only processed 75 people and was over

very quickly. If an actual event was occurring, this process could go on for several hours and

even though the night, not to mentionwith hundreds to thousands of more people. Preparing POD

workers to do their job is important, but not demonstrating to them the mental challenge of

pushing on past their normal limits to accomplish their mission and deliver the medicine to the

public is not possible in a small exercise. This is a great challenge that was not addressed at all at

the exercise and could prove to be the one of the more critical challenges in the case of an actual

event.

Concerning all the observations that were made that demonstrated a need for

improvement, most fell under the planning aspect of the core capabilities. There were many
 positive outcomes that happened during the exercise. The staff members were excited, ready to

be there, stayed under control, and did what they were meant to do. The staff members were not

expecting many of the issues but were trained well enough to cope with them and alleviate

problems before they escalated out of control. The exercise was set up quickly and in an orderly

fashion. The POD was easy to follow from an individuals perspective and created a sense of

understanding of what would need to happen if an event was actually going to occur.

Background

FEMA has directly outlined a guide for creating and running a point of distribution. The

guide contains protocols for different POD sizes, staffing allocation and responsibilities, and how

to interact with local law enforcement [2]. FEMA also has a document entitled IS-139 which

contains a unit called The Full-Scale Exercise. FEMA claims that some people believe that a

full-scale exercise can run on its own once it is started. However, they state that this is a

misconception and that such an exercise cannot run without time, money, personnel, expertise,

and preparation. Five specific bullet points are addressed on that note [3]:

Substantial experience with preparatory exercises of various kindsdrills, tabletops, and

functional exercises.

Total commitment of all emergency service organizations.

Support from the chief elected and/or appointed officials.

Adequate physical facilities, including space for the EOC and field command posts.

Adequate communication facilities (e.g., radios and telephones).

 FEMA also produced a Core Capabilities document which outlines 31 different

capabilities that FEMA believes are critical elements needed to achieve the goal. There are

several which apply to a full-scale exercise more than the rest. Public information and warning

should be taken into account during the preparation of panning an exercise. The public needs to

be informed of what is going on to help keep them calm and collective or at least as calm as

possible in a mass distribution exercise. If the public is unaware that there is an actual

distribution going on, they need to know what they should do to acquire the medication and what

it is they are receiving. Another important capability is intelligence and information sharing. This

seems extremely important because certain areas of the country will need to know what is

happening elsewhere in the nation during an actual event. If information isnt properly shared,

then it will be difficult to overcome the problem and will slow down the recovery process. Other

important capabilities may include critical transportation, fatality management services, and

operational communications [1].

In addition to FEMAs documents, the Texas Department of State Health Services

published the Health and Medical Exercise & Evaluation Program Exercise Guidance. They

demonstrate the importance of staying within Homeland Security Exercise and Evaluation

Program (HSEEP) doctrine throughout the exercise. The first step is to conduct an annual

Training and Exercise Plan Workshop (TEPW), and maintain a Multi-Year Training & Exercise

Plan. This is a good practice to follow because the people involved can change from year to year,

and people can forget what to do when a real exercise is needed. If people are not reminded of

how to perform then chaos could result. The second step is to plan and conduct exercises in

accordance with the guidelines set forth in HSEEP policy. This includes the use of various types

of planning conferences and exercise documentation. The number of conferences and types of
documentation required are flexible and are dependent on the full scope of the exercise. Planning

always needs to be done to make sure that ideas are generated and all types of problems can be

discussed and worked on to determine how to execute the exercise effectively. The third step is

to develop and submit a properly formatted After Action Report/Improvement Plan. This might

be the most important step because learning from the past and the after action report can tell the

planners what needed to be performed better and what worked well. This falls back to the first

step of having annual exercises so people can learn and develop better and more efficient ways

of handling the distribution process. The last step could be implemented in the previous and is to

track and implement corrective actions identified in the AAR/IP. This simply means following up

with correcting the problematic parts of the exercise and keeping track of the corrections to make

sure that, if the corrections dont create a better outcome the next time, that the same mistake is

not made again [4].

AnyLogic ModelMethods

To replicate the events that occurred in the exercise, a computer simulation model was

created by graduate students at Purdue University [5]. The model uses a discrete event approach.

Discrete event modeling is used in low-to-mid level abstraction models. It is typically used for

modeling large operations and tactical decision making. The model works like a flow chart with

passive objects, known as entities, passing through. Discrete event modeling allows the user to

allocate resources to perform different tasks. Borshchev, Karpov, and Kharitonov are experts in

the modeling software called AnyLogic. They claim that AnyLogic is one of the best programs

for creating discrete event models in the world [6]. AnyLogic is widely used in both industry and

academia. Along with its discrete event modeling capabilities, it also allows users to create
agent-based and system dynamics models or even combinations of all three types. AnyLogic is

also very useful for dealing with staff scheduling. Though a full-scale exercise may not have

shift changes, an actual POD would require them if it was to run through the night. AnyLogic

allows shift schedules to be varied to find the optimal schedule for both the workers and the

people requiring each service [7].

Discrete event modeling was used to create the POD model in this research. The benefits

of discrete event modeling allow for accurate representation of the POD within the software. The

flowchart-based approach allows the flow of a pedestrian through the POD to be modeled as a

sequential set of events, just as the events would appear in the real world. Many of the modeling

techniques used in the POD model were also used to model another complicated facility, called a

Regional Hub Reception Center by Kirby, Dietz, and Wojtalewicz in 2012. Like the POD model,

it used the discrete event approach to move thousands of evacuees through a short-term shelter to

assist in the evacuation of a major city. Though the subject matter of both models is different, the

approach of modeling the overall system as a set of smaller systems with people flowing through

a queuing process is identical [8].

The POD exercise held on April 15, 2014 at the Tippecanoe County Fairgrounds in

Indiana allowed for the collection of real world data to populate the model. That data is shown in

Table 1, and units are measured in seconds. The table includes the actor number which

corresponded to each tracked individual passing through the POD. Each of the four station

completion times are shown in addition to the total time each individual took to make it through

the POD and how much downtime they had from waiting in lines or waiting for instructions.

Actor # Triage Registratio Screening Dispensing Total Down

 n Time
1 8 16 90 540 426
1B 8 73 20 62 373 210
3 21 165 178 102 587 121
3B 19 33 56 57 378 213
6 710 99 94 1064 161
6B 18 153 45 19 338 103
8B 12 121 34 52 308 89
8 2 115 87 64 362 94
14B 20 266 50 113 639 190
14 19 40 254 80 714 321
15 359 634 275
17 10 60 33 44 247 100
21 20 285 43 3 629 278
21B 37 159 71 441 174
25B 45 210 52 44 530 179
26 225 135 36 34 568 138
28B 180 131 428 814 75
30B 8 284 91 92 600 125
33 63 200 21 29 511 198
41B 75 37 86 -198
42 105 37 50 295 103
43 10 90 20 34 382 228
44B 8 35 18 58 470 351
45B 123 12 37 261 89
46 23 97 19 -139
47B 6 111 36 30 281 98
51 25 35 23 265 182
54B 11 40 39 352 262
55 10 30 43 46 424 295
56 15 15 31 297 236
58 10 334 324
60 147 48 37 394 162
65 9 146 34 38 310 83
66 18 114 25 52 369 160
69 32 140 26 32 366 136
72 24 32 31 271 184
74 10 25 34 35 302 198

Averages 33.80769 126.4324324 66.742857 49.4516129 447.1429 168.2162

Table 1. Data collected from POD exercise
 The registration process was recorded differently by the data collectors. Some of the data

collectors only recorded the time it took for the individual to talk to the registration worker and

receive their paperwork. Other data collectors also included the time it took each individual to

fill out their paperwork. Because of this, Table 2 shows the data separated out into each of the 2

types.

Actor # Talking Paperwork

1 16
1B 73
3 165
3B 33
6 710
6B 153
8B 121
8 115
14B 266
14 40
15 359
17 60
21 285
21B 37
25B 210
26 135
28B 131
30B 284
33 200
41B 37
42 105
43 90
44B 35
45B 123
46 97
47B 111
51 25
54B 11
55 30
56 15
58 10
60 147
 65 146
66 114
69 140
72 24
74 25

Averages 31.4 191.2273

Table 2. Registration data by type

When the model is launched, the user is prompted with the model setup screen, shown in

Figure 1. This screen allows the user to run the model with a set of manual inputs. The default

values of 2, 6, 8, and 16 are shown. However, the user can manipulate these values to any integer

greater than or equal to 1. These parameters refer to the number of workers at each of the four

stations. The number of workers at a station determines that stations maximum number of

people the station can handle at any one moment because it is assumed that one worker can

process one person at a time. After the parameters are set, the user can press the Run the model

and switch to Main view button, which will bring the user to the Main view of the simulation

where the model can be seen running in action. It is important to note that the POD exercise

tested multiple queuing methods. Chan discusses how different human behavior can result from

different queuing systems being used in simulation [9]. One such behavior that occurred during

the exercise was when a funneling queue system was used. Because multiple stations converged

into a single-line funnel, the lines became disorganized, and some people actually moved ahead

of others by passing them in the funnel. This could result in confrontations in a real world

situation. Because of this, the queues used in the POD model are all assumed to be serpentine

and single-file.
 Figure 5. Model setup screen

After the user presses the button, the Main view shows the discrete event framework of

the model logic, which can be seen in Figure 2. The processes that people needing medication

must pass through are:

1. Enter the POD

2. Wait in the Triage queue
3. Triage
4. Wait in the Registration queue
5. Registration
6. Wait for an empty seat at a table
7. Fill out registration paperwork
8. Wait in the Screening queue
9. Screening
10. Wait in the Dispensing queue
11. Dispensing
12. Exit the POD

Figure 2. Main view

Once the model is running, each process shows three numbers. The blue number on the

bottom left represents the number of people who have begun the process. The blue number on

the bottom right represents the number of people who have finished the process. The green

number on top represents the number of people currently in the process. As people pass through

the model, the colors of the processes change to indicate each process current status. White

means the process is empty. Yellow means the process is currently processing some people.

Orange means the process is at maximum capacity. When a process is at maximum capacity,

anyone needing to complete the process must wait in that process respective queue. These

properties are shown in Figure 3.

 Figure 3. Model in action

Queues are assumed to have no maximum capacity. In a real world scenario, a maximum

queue capacity could be inserted based upon the given number of people the actual queue could

hold. The model could perform tests to show if a given queue capacity will be able to hold all of

the people passing through the POD.

The results of the model appear in the orange box below the model logic. An enhanced

view of the results is shown in Figure 4. The results displayed for the model only include the

total time for the POD to process all 20,000 people. In this particular model run, the processing

time for 20,000 people given the default inputs was 340, 315 seconds, or 3 days 22 hours and 32

minutes.
 Figure 4. Results

The model was used to optimize the number of staff needed at each position in the POD.

Since 32 staff members covered the 4 positions during the POD exercise, the number 32 was

assumed to be static for the optimization process. The allocation of those 32 staff members was

adjusted for each model run using AnyLogics optimization techniques. AnyLogic uses a piece of

software called OptQuest for optimizing simulation models. OptQuest takes a set of predefined

inputs and adjusts them according to minimums, maximums, and constraints set for each

parameter by the user. The software runs either a set amount of simulations or until all possible

solutions have been tested. Optimizing the POD model required fewer than 3000 model runs to

complete, so all possible solutions were tested.

Results

Because multiple PODs may be used in a real disaster, and the size of those PODs may

vary, values of 5000 10,000, 15,000, and 20,000 were used for the number of people the POD

needs to process. The four scenarios were all optimized to keep the total operation time to a

minimum. Figure 5 shows the optimization process as it appears in AnyLogic.

 Figure 12. Basic scenario

The Iteration line shows the current and best model runs. The Objective line below shows

the current and most optimal results. The Parameters list shows the parameters being tested and

the parameters which contributed to the best result. The chart to the right shows all of the model

runs and their respective results given the objective. The results of the optimizations are shown

in Table 3 including how many people came through the POD, the new optimized time compared

to the old non-optimized time, and how many working hours were saved given the optimization.

Number Working
of Hours
People New Time Old Time Saved
20000 33.9 hours 94.5 hours 1939
15000 25.5 hours 70.9 hours 1453
10000 17.0 hours 47.3 hours 970
5000 8.5 hours 23.7 hours 486

Table 3. Optimized results

Conclusion

Through the use of optimization modeling, major improvements can be made to the

original staffing allocation that was used for the POD exercise. Performing the less than 3000

model runs for a given number of people passing through the POD took less than 5 minutes.

Spending 5 minutes on an optimization before launching an operation to process 20,000 people

would save 1939 working hours. This would not only decrease the working hours for each staff

member, but it would also decrease the cost of running the POD. Less time running the POD

would also mean less overhead costs on support services, electricity, food, and any other

necessities.

Further research can be performed to allocate more or less than 32 staff members, the

materials they need, additional resources and personnel, and the drugs being dispensed. Each

individual POD will have its own set number of tables at each station and corresponding staff

members. It will also have its own set number of distributable doses of the drug. A finished

product of the model could be used worldwide by allowing planners to input their own needs and

constraints and then perform their own optimization problems to suit their needs. An additional

approach to add to the POD model could be to implement agent-based characteristics. Such

characteristics would allow complex interactions between humans, deal with people in a limited

amount of space, allow the population to be heterogeneous, allow the interactions to be complex,

and allow agents to execute complex behavior [10]. These characteristics could help create an

even more accurate model. AnyLogic could also allow for the inclusion of dispensing trucks to

be scheduled for travel to and from the POD [11].

 Overall, the operation of the POD exercise was a success. However, optimizing the
process will help to save costs and make the process run much more smoothly. Multiplying the
optimization results of this study across multiple PODs for a city or across the nation could
decrease the time it takes to distribute life-saving medication to citizens in a much shorter
amount of time, greatly improving the success of stopping the illness from spreading.
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