The Mountain Plains Regional Disaster Health Response System (Mountain Plains RDHRS) works to build disaster capacity across US Federal Region VIII, a rural western six-state region. It conducts an annual rehearsal of concepts and exercises to identify gaps and inform policy development. In 2022, a multi-state exercise was conducted involving responders from individual hospitals coordinating with Healthcare Coalitions and State Public Health. These responses rolled up to a multi-state emergency operations center overseen by the Mountain Plains RDHRS.

A fictitious mass multi-state botulism incident generated a pediatric surge across the region. Individual patient cards with demographic information were given to a set of hospitals in participating states. The communication pathways within states were identified. Communication between local and regional pediatric transfer centers were assessed. Overall situational awareness was tracked.

The exercise format was incident occurrence and notifications by normal channels and a Zoom conference call held on day one. Situational awareness and patient movement occurred in multiple Zoom rooms on day two. An after-exercise review occurred by Zoom on day three including all participants from the exercise.

There was generally good information flow within states, but minimal information exchange across states There was poor regional situational awareness with a lack of complete patient lists and transfers. The Mountain Plains RDHRS planned to exceed the hospital’s patient capacities with a large number of pediatric patients to practice patient movement across state lines. Instead the hospitals showed a surprising willingness to keep and manage critical pediatric patients instead of transferring to tertiary care pediatric centers. This was identified as a consequence of the COVID-19 experience.

Web-based exercises vertically spanning responses from individual hospitals to multi-state regional entities are feasible. This exercise demonstrated multiple gaps in regional disaster response.