Preparing for Terrorism

Tools for Evaluating the Metropolitan Medical Response System Program

Frederick J. Manning and Lewis Goldfrank, Editors

Committee on Evaluation of the Metropolitan Medical Response System Program

Board on Health Sciences Policy

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.



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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program Preparing for Terrorism Tools for Evaluating the Metropolitan Medical Response System Program Frederick J. Manning and Lewis Goldfrank, Editors Committee on Evaluation of the Metropolitan Medical Response System Program Board on Health Sciences Policy INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C.

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program NATIONAL ACADEMY PRESS 2101 Constitution Avenue, NW Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for this report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the Office of Emergency Preparedness, U.S. Department of Health and Human Services (Contract No. 282-99-0045, TO#5). This support does not constitute endorsement of the views expressed in the report. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee on Evaluation of the Metropolitan Medical Response Program. Preparing for terrorism : tools for evaluating the Metropolitan Medical Response System program / Frederick J. Manning and Lewis Goldfrank, editors ; Committee on Evaluation of the Metropolitan Medical Response System Program, Board on Health Sciences Policy, Institute of Medicine. p. ; cm. Includes bibliographical references. ISBN 0-309-08428-8 (pbk.) 1. Disaster medicine. 2. Emergency medical services. 3. Terrorism—Health aspects. 4. Weapons of mass destruction—Health aspects. 5. Emergency management. 6. Health planning. [DNLM: 1. Disaster Planning—organization & administration. 2. Emergency Medical Services—organization & administration. 3. Health Planning. 4. Program Evaluation—methods. 5. Terrorism. WX 185 I59p 2002] I. Manning, Frederick J. II. Goldfrank, Lewis R., 1941- III. Title. RA645.5 .I54 2002 362.18—dc21 2002007502 Additional copies of this report are available for sale from the National Academy Press, 2101 Constitution Avenue, NW , Box 285, Washington, DC 20055. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP’s on-line bookstore at www.nap.edu. The full text of the report is available on-line at www.nap.edu For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright 2002 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program "Knowing is not enough; we must apply. Willing is not enough; we must do." —Goethe INSTITUTE OF MEDICINE Shaping the Future for Health

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program THE NATIONAL ACADEMIES National Academy of Sciences National Academy of Engineering Institute of Medicine National Research Council The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chairman and vice chairman, respectively, of the National Research Council.

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program COMMITTEE ON EVALUATION OF THE METROPOLITAN MEDICAL RESPONSE SYSTEM PROGRAM LEWIS GOLDFRANK (Chair), Director, Emergency Medicine, New York University Medical Center, Bellevue Hospital Center, New York, New York JOSEPH BARBERA, Director, Disaster Medicine Program, The George Washington University, Washington, DC GEORGES C. BENJAMIN, Secretary, Maryland Department of Health and Mental Hygiene, Baltimore, Maryland JAMES BENTLEY, Senior Vice President, Strategic Policy Planning, American Hospital Association, Washington, DC KENNETH I. BERNS, President and CEO, Mount Sinai Medical Center, New York, New York RAYMOND M. DOWNEY, Battalion Chief and Chief of Rescue Operations, Special Operations Command, Fire Department, City of New York (from November 2000 to September 2001) FRANCES EDWARDS-WINSLOW, Director, Office of Emergency Services, San Jose, California LINDA F. FAIN, Disaster Mental Health Consultant, Auburn, California FRED HENRETIG, Director, Clinical Toxicology, and Director, Poison Control Center, Children’s Hospital of Philadelphia, Pennsylvania DARRELL HIGUCHI, Deputy Chief, Los Angeles County Fire Department, Los Angeles, California (from November 2001) ARNOLD HOWITT, Executive Director, Taubman Center, Kennedy School of Government, Harvard University, Cambridge, Massachusetts LAURA LEVITON, Senior Program Officer for Research and Evaluation, Robert Wood Johnson Foundation, Princeton, New Jersey WILLIAM MYERS, Health Commissioner, Columbus, Ohio DENNIS M. PERROTTA, State Epidemiologist and Chief, Bureau of Epidemiology, Texas Department of Health, Austin, Texas JEFFREY L. RUBIN, Chief, Disaster Medical Services Division, Emergency Medical Services Authority, State of California, Sacramento, California AMY E. SMITHSON, Senior Associate, Henry L. Stimson Center, Washington, DC (from November 2000 to July 2001) DARREL STEPHENS, Chief, Charlotte-Mecklenburg Police Department, Charlotte, North Carolina

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program Board on Health Sciences Policy Liaison BERNARD GOLDSTEIN, Dean, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania Study Staff FREDERICK J. MANNING, Study Director REBECCA LOEFFLER, Project Assistant Institute of Medicine Staff ANDREW POPE, Director, Board on Health Sciences Policy ALDEN CHANG II, Administrative Assistant, Board on Health Sciences Policy CARLOS GABRIEL, Financial Associate Consultant LAUREN SCHIFF, Incident Commander and Operations Officer, Appalachian Search and Rescue Conference, Charlottesville, Virginia.

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program Independent Report Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The contents of the review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their participation in the review of this report: MARTIN BLASER, Professor of Internal Medicine and Chair, Department of Medicine, New York University GREGORY M. BOGDAN, Research Director and Medical Toxicology Coordinator, Rocky Mountain Poison Center, Denver, Colorado BARRY S. COLLER, David Rockefeller Professor of Medicine, Physician-in-Chief, The Rockefeller University Hospital, and Vice President for Medical Affairs, The Rockefeller University, New York, New York GEORGE R. FLORES, Director of Public Health, San Diego Department of Health, San Diego, California VINCENT T. FRANCISCO, Associate Director, Work Group on Health Promotion and Community Development, University of Kansas, Lawrence, Kansas

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program ROBERT MALSON, President, District of Columbia Hospital Association, Washington, D.C. PAUL M. MANISCALCO, Past President, National Association of Emergency Medical Technicians PETER ROSEN, Director, Emergency Medicine Residency Program, Department of Emergency Medicine, University of California, San Diego School of Medicine ROBERT E. SHOPE, Professor of Pathology, University of Texas Medical Branch, Galveston, Texas Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by LESTER N. WRIGHT, Chief Medical Officer, New York Department of Correctional Services, Albany, New York, appointed by the Institute of Medicine, and ALEXANDER H. FLAX, Consultant, Potomac, Maryland, appointed by the NRC’s Report Review Committee. These individuals were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program This report is dedicated to Ray Downey, Chief of Rescue Operations, Fire Department, City of New York, our friend and colleague on this Institute of Medicine committee, killed in the line of duty while leading rescue efforts at the World Trade Center after the terrorist attack on September 11, 2001.

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program Preface Having a vision, a mission, and a passion are invariably seen as conditions for success. The 1995 U.S. Department of Health and Human Services (DHHS) concept of a Metropolitan Medical Response System (MMRS) demonstrated that the leaders of DHHS had a vision for an effective response to a mass-casualty terrorism incident with a weapon of mass destruction. The mission was to expand the experimental model of the Metropolitan Medical Strike Team (MMST) established in Washington, D.C., and neighboring counties into a national program. The problem that the Office of Emergency Preparedness (OEP) of DHHS faced was the dilemma of knowing what preparedness is and determining whether preparedness could be recognized if it was achieved. Under these circumstances, OEP requested that the Institute of Medicine determine how effective this MMRS program effort is and how valuable it could become. A typically diverse Institute of Medicine working group consisting of leaders, strategists, practitioners, and analysts of societal needs in terms of readiness for disasters and terrorism with weapons of mass destruction was established in the autumn of 2000. Over the following 18 months we constructed a diversified analytic program that emphasizes continuous quality improvement to enhance relationships, understanding, and services, and improve equipment and personnel in the pursuit of preparedness. Our approach is based on the belief that all services are valuable, that they must be integrated, and that shared leadership with democratic, open management approaches will effectively be able to use each metro-

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program politan region’s assets. We have suggested that document and data analysis, site visits by a team of expert peer reviewers, and observations of exercises and drills be used to analyze a region’s accomplishments. Some committee members’ theoretical approaches to the requirements of this project as well as the limited cooperative spirit seen in some MMRS program efforts were initial concerns for the committee. These limitations to the committee’s potential were dramatically altered by the September 2001 assault that toppled the World Trade Center and paralyzed the U.S. aviation system and by the mailing of anthrax-laden letters in October 2001 that almost toppled the U.S. public health and postal systems. The events led to the tragic death of a fellow committee member, Ray Downey, Chief of Rescue Operations, Fire Department, City of New York, and thousands of other Americans. These terrorist acts led to a disruption of the equanimity not just of New York City but of our entire country. Our committee, recognizing the timeliness and exceptional importance of our task, responded with the necessary passion to complete the tasks of this analytic process. We believe that this product will allow OEP, state and federal governments, and all who create preparedness teams to offer a more informed, qualified, and integrated approach to preparedness and public health. This report will be an essential tool in analyses of the depth and breadth of governmental performance and interagency collaboration. This effort—and in particular, U.S. society’s recognition of the importance of our goals—will allow us to save lives and property in future biological, chemical, and radiological terrorist events. The vision was of vital importance. We hope that our passion has allowed us to accomplish the mission and that OEP will have the tools that it needs to determine if we in America are ready to protect ourselves from unknown potential assaults and will remain so for the future. Lewis R. Goldfrank Chair

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program Acronyms and Abbreviations ARC American Red Cross CAR Capability Assessment for Readiness CBR chemical, biological, and radiological CBRDT Chemical/Biological Rapid Deployment Team CDC Centers for Disease Control and Prevention CDP Center for Domestic Preparedness (U.S. Department of Justice) CHER-CAP Comprehensive HAZMAT Emergency Response-Capability Assessment Program CSEPP Chemical Stockpile Emergency Preparedness Program DHHS U.S. Department of Health and Human Services DMAT Disaster Medical Assistance Team DMORT Disaster Mortuary Team DOD U.S. Department of Defense DOE U.S. Department of Energy DOJ U.S. Department of Justice DVA U.S. Department of Veterans Affairs ED emergency department EOC Emergency Operations Center EOP emergency operations plan EMAC emergency management assistance compact EMI Emergency Management Institute

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program EMS emergency medical services EPA Environmental Protection Agency ESF emergency support functions FBI Federal Bureau of Investigation FEMA Federal Emergency Management Agency FRP Federal Response Plan FY fiscal year GAO General Accounting Office Hazmat hazardous materials HDS Hazardous Devices School HMO health maintenance organization IOM Institute of Medicine JCAHCO Joint Commission for Accreditation of Healthcare Organizations LCAR Local Capability Assessment for Readiness LEPC Local Emergency Planning Committee MEMA Maryland Emergency Management Agency MMRS Metropolitan Medical Response System MMST Metropolitan Medical Strike Team MOU memorandum of understanding NAPA National Academy of Public Administration NCP National Contingency Plan or National Oil and Hazardous Substances Contingency Plan NDMS National Disaster Medical System NDPC National Domestic Preparedness Consortium NDPO National Domestic Preparedness Office NEMA National Emergency Management Association NMRT National Medical Response Team OCFD Oklahoma City Fire Department OCPD Oklahoma City Police Department ODP Office of Domestic Preparedness (U.S. Department of Justice) OEP Office of Emergency Preparedness OES Office of Emergency Services

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program OMB Office of Management and Budget OSHA Occupational Safety and Health Administration OSLDPS Office of State and Local Domestic Preparedness Support POC point of contact REP Radiological Emergency Preparedness Program (Federal Emergency Management Agency) ROC Regional Operations Center SOP standard operating procedure USAR U.S. Army Reserve USNRC U.S. Nuclear Regulatory Commission VA Department of Veterans Affairs VMI vendor-managed inventory WMD weapons of mass destruction

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program Contents     EXECUTIVE SUMMARY   1     Charge to the Committee,   2     Chemical, Biological, and Radiological Weapons,   3     The MMRS Program,   5     Existing Emergency Response Systems,   6     Other Federal Programs to Strengthen Local Capabilities,   7     Feedback to OEP on Program Management,   7     Feedback to OEP on Program Success,   8     Closing Remarks,   14 1   INTRODUCTION   17     Chemical, Biological, and Radiological Terrorism,   18     The MMRS Program,   23     Charge to the Committee,   26     Methods of the Present IOM Study,   28     Organization of This Report,   30 2   COMMUNITY EMERGENCY MANAGEMENT AND AVAILABLE FEDERAL ASSISTANCE   31     Emergency Management Terminology,   32     Emergency Management in the United States,   34     Local Emergency Management,   36     State Assistance,   40     The Federal Emergency Response Plan,   42     The National Contingency Plan,   47

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program     The Federal Radiological Emergency Response Plan,   48     Terrorism-Specific Federal Support Teams,   48     Conclusion,   50 3   FEDERAL EFFORTS TO INCREASE STATE AND LOCAL PREPAREDNESS FOR TERRORISM   52     ODP Programs,   53     FBI Programs,   57     CDC Programs,   58     FEMA Programs,   60 4   METROPOLITAN MEDICAL RESPONSE SYSTEM PROGRAM CONTRACTS   66     Functional Areas Covered,   67     Products Demanded,   68     Contract Deliverable Evaluation Instrument,   74 5   MEASUREMENT AND DATA COLLECTION IN EVALUATION   75     Evaluations of Various Types,   76     Management Functions of Evaluations in the MMRS Program Context,   78     Summative and Formative Uses of Various Evaluation Types,   81     Why an Adequate Written Plan Is Not Sufficient Assurance of Preparedness,   82     Evaluation Measurement for Low-Frequency, High-Stakes Events,   85     Evaluation Measurement: Performance Measures and Proxies,   86     Criteria for Selection of Evaluation Methods,   87 6   PREPAREDNESS INDICATORS   91     Existing Standards,   92     Existing Assessment Tools,   94     Performance Measures Versus Preparedness Indicators,   97 7   FEEDBACK TO OFFICE OF EMERGENCY PREPAREDNESS ON PROGRAM MANAGEMENT   100     OEP Help to MMRS Program Contractors,   102     Survey for MMRS Program Contractors,   105 8   FEEDBACK TO OFFICE OF EMERGENCY PREPAREDNESS ON PROGRAM SUCCESS   113     Essential Response Capabilities,   115

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program     Preparedness Indicators for Evaluation of Written Submissions, On-Site Inspection, and Observed Exercises,   118     Preparedness Criteria,   118     Exercises and Drills,   159     Site Visits and Peer Evaluators,   160     Scenario-Driven Group Interaction,   161     Summary,   162 9   CLOSING REMARKS   164     Strategic Uses of Evaluation Data: Implementing the “Layering Strategy”,   166     Committee Critique and Suggestions for Program Amendments,   169     REFERENCES   171     APPENDIXES     A   Committee and Staff Biographies,   177 B   Selected Information About Federal Chemical, Biological, Radiological, Nuclear Consequence Management Response Teams,   187 C   Metropolitan Medical Response System Program Cities,   198 D   2000 MMRS Contract Deliverable Evaluation Instrument,   200 E   Preparedness Indicators for Metropolitan Medical Response System Program Contract Deliverables,   219 F   Scenarios and Discussion Materials for Use on Site Visits,   252 LIST OF TABLES, FIGURES, AND BOX Tables 1-1   Chemical Agents and Their Effects,   19 1-2   Biological Agents, Effects, Characteristics, and Medical Countermeasures,   24 8-1   Preparedness Indicators and Mode of Evaluation of MMRS Plan Elements Relevant to Each of 23 Essential Capabilities,   120

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program Figures ES-1   Relationships among essential capabilities, preparedness indicators, preparedness criteria, and data collection methods,   13 1-1   Flow chart of probable actions in a chemical or overt biological agent incident,   20 1-2   Flow chart of probable actions in a covert biological agent incident,   22 2-1   Key federal consequence management response teams for CBR terrorism,   49 5-1   MMRS program participants, policy instruments, development activities, emergency capacity, and follow-up activities,   77 5-2   Accountability relationships for federal grantees and grant-making agencies,   79 Box ES-1   Example of Preparedness Indicator for One Essential Capability, First Responder Protection,   12

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program Preparing for Terrorism

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