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Tools for Evaluating the Metropolitan Medical Response System Program: Phase I Report

Committee on Evaluation of the Metropolitan Medical Response Program

Board on Health Sciences Policy

INSTITUTE OF MEDICINE

Frederick J. Manning and Lewis Goldfrank, Editors

NATIONAL ACADEMY PRESS
Washington, D.C.



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

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Tools for Evaluating the Metropolitan Medical Response System Program: Phase I Report 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. This support does not constitute endorsement of the views expressed in the report. International Standard Book Number 0-309-07647-1 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/readingroom. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright 2001 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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Tools for Evaluating the Metropolitan Medical Response System Program: Phase I Report 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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Tools for Evaluating the Metropolitan Medical Response System Program: Phase I Report 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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Tools for Evaluating the Metropolitan Medical Response System Program: Phase I Report COMMITTEE ON EVALUATION OF THE METROPOLITAN MEDICAL RESPONSE 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 KENNETH I.BERNS, Vice President for Health Affairs and Dean, College of Medicine, University of Florida, Gainseville, Florida. RAYMOND M.DOWNEY, Battalion Chief and Chief of Rescue Operations, Special Operations Command, Fire Department City of New York (11/00 to 9/01) FRANCES EDWARDS-WINSLOW, Director, Office of Emergency Services, San Jose, California LINDA F.FAIN, Disaster Mental Health Consultant, Auburn, CA FRED HENRETIG, Director, Clinical Toxicology, Director, Poison Control Center, Children’s Hospital of Philadelphia. 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 (11/00 to 7/01) BARREL STEPHENS, Chief, Charlotte-Mecklenburg Police Department, Charlotte, NC Board on Health Sciences Policy Liaison BERNARD GOLDSTEIN, Dean, Graduate School of Public Health, University of Pittsburgh 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, Board Administrative Assistant CARLOS GABRIEL, Financial Associate

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Tools for Evaluating the Metropolitan Medical Response System Program: Phase I Report 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 NRC’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 review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: GREGORY M.BOGDAN, Research Director and Medical Toxicology Coordinator, Rocky Mountain Poison & Drug Center, Denver, Colorado 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 SALVATORE S.LANZILOTTI, Director, Honolulu Emergency Services Department, Honolulu, Hawaii 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, University of California, San Diego School of Medicine ROBERT E.SHOPE, Professor of Pathology, University of Texas Medical Branch, Galveston, Texas LESLEE STEIN-SPENCER, Chief, Division of Emergency Medical Services and Highway Safety, Illinois Department of Public Health, Springfield, Illinois 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, who was 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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Tools for Evaluating the Metropolitan Medical Response System Program: Phase I Report 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, lost to us while leading rescue efforts at the World Trade Center after the terrorist attack on September 11, 2001.

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Tools for Evaluating the Metropolitan Medical Response System Program: Phase I Report Preface When our committee began in the fall of 2000 to evaluate the potential of the Metropolitan Medical Response System (MMRS) program to enhance local ability to respond to the consequences of weapons of mass destruction terrorism, I could not have imagined the tragedies that would befall us as committee members and as a society. Many of us on the committee have had personal losses from the assault on the World Trade Center and on our sense of physical and psychological safety. We are all deeply saddened by the death of Raymond Downey a longtime fire department veteran and expert in urban search and rescue who was a key committee member. His death is a great loss and his wisdom and leadership on our committee will be sorely missed. My department of emergency medicine at New York University Medical Center was among the hospitals that treated the critically ill and injured on September 11, 2001 and helped many individuals cope with traumatic stress in the ensuing weeks. Now the department is focusing immense energy on preparedness for potential future terrorist actions. Committee member Fred Henretig was involved in the care of victims and rescuers in New York as a member of a Disaster Medical Assistance Team from the Philadelphia area, and committee member Joe Barbera provided on-site advice on search and rescue operations at both the World Trade Center and the Pentagon. Although much of the work described in this report was completed prior to September 11, 2001, our analysis of the MMRS program and means to assess it remain valid. This disaster has taught us: that decentralization of our resources is essential; that communications with rescue- and hospital-based systems are fragile; that the psychological impact on the families, friends, coworkers, city and country members cannot be overestimated; that hospital readiness may be far greater than is widely believed, even if severely compromised in the midst of disaster; that massive private and public resources can be mobilized very rapidly and very effectively in the face of a disaster; and that the enormous altruism and humanism of Americans permit a civic response that rapidly leads to optimism in the face of crisis and reaffirmation of the power of a democratic society. This horrible event has allowed those of us working in New York City hospitals to understand terrorism better through the actions of our patients: the walking wounded who stayed away from healthcare for several weeks, the seriously ill who waited hours so as not to burden us, and the many suffering people who wished to talk, cry or sit in our healthcare centers. The events of this Fall will allow people at all levels in our society to appreciate the importance of the MMRS concept. It is my belief that our committee’s work will greatly aid the efforts of the Office of Emergency Preparedness (OEP) to analyze the disaster readiness of our cities. It is obvious that greater resources, stronger commitment to broader preparedness involvement and the study of terrorism, clearer understanding of the issues in question, and true interagency collaboration should follow logically from the recent terrorist assault. These changes in governmental vision and leadership will be essential to not only meet the letter, but the spirit of the contracts OEP has been signing with major cities. It is our hope that by analyzing preparedness we will decrease the risk from natural and intentional assaults on our environment and our well being. We look forward in the second part of our project to developing creative strategic mechanisms for improving OEP analysis of preparedness for biological, chemical, and radiological terrorism. Our country and our people are entitled to a national approach to these problems based on a strong public health system. We, as a committee, are more motivated than ever to enhance mechanisms for assessing our country’s preparedness. Lewis Goldfrank Chair October 10, 2001

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Tools for Evaluating the Metropolitan Medical Response System Program: Phase I Report Contents     INTRODUCTION   1     CHARGE TO THE COMMITTEE   2     METHODS   2     INITIAL OBSERVATIONS   3     MMRS PROGRAM CONTRACTS   6     ANSWERS TO SPECIFIC QUESTIONS ASKED BY OEP   7     PERFORMANCE MEASURES AND PREPAREDNESS INDICATORS   15     APPENDIX: PREPAREDNESS INDICATORS   19

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