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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program (2002)

Chapter: 8 Feedback to Office of Emergency Preparedness on Program Success

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Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

8
Feedback to Office of Emergency Preparedness on Program Success

Regardless of how the Metropolitan Medical Response System (MMRS) program is managed by the U.S. Department of Health and Human Services’ Office of Emergency Preparedness (OEP), the ultimate test of the program’s worth lies in how well it has helped local communities prepare for the consequences of a massive terrorist attack with chemical, biological, or radiological (CBR) weapons. The survey described in the previous chapter begins to answer this question by soliciting the opinions of the communities themselves. This chapter complements that approach by presenting the recommendations of the Committee on Evaluation of the Metropolitan Medical Response System Program for an independent and systematic assessment of the response capabilities of the large metropolitan areas that have or will participate in the MMRS program. The title to the chapter was chosen to emphasize an important assumption or guiding principle of the committee: that program assessment is primarily for the purpose of identifying and correcting shortfalls in OEP’s MMRS program. Several other interrelated principles also underlie the chapter and the committee’s recommendations:

  • Evaluation should be part of a continuous learning and continuous quality improvement program, not a one-time snapshot. This implies a continuing relationship between the communities and their evaluators that includes financial as well as technical and educational support.

  • “Preparedness” is a meaningless abstract concept, since threats vary among communities and change over time, perhaps even in response

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

to a community’s level of preparedness; readiness should be seen as a process rather than a state.

  • Preparedness requires not only numerous specific capabilities, typically the responsibilities of independent offices, agencies, and institutions, but also seamless coordination of those capabilities into a coherent response. The former may be envisioned as the teeth of a comb, the latter as the base or backbone of the comb.

  • Information and the ability to acquire, process, and appropriately distribute it to essential sites and personnel are central to the effective management of critical incidents including terrorism in its many forms.

  • Evaluation is an exercise designed to guide the distribution of local, state, and federal resources. Evaluations should be valued and understood as an opportunity for local communities to determine the areas in need of improvement and support rather than as a test of communities’ self-reliance.

  • Evaluation by OEP should be a multilevel process that includes (1) periodic review of documents and records, (2) observation of community-initiated exercises and drills, and (3) on-site assessment. The committee views the on-site assessment as comprising both interviews of individuals about specific capabilities and a scenario-driven group interaction focused on cooperation and coordination.

  • A relatively small subset of the nearly 500 preparedness indicators identified in the Phase I report (Institute of Medicine, 2001) can be used to identify critical areas in need of improvement for a given community.

As noted earlier in the report, in the absence of any proper control cities or pre-MMRS data, it will be impossible to unequivocally assign credit to OEP for high states of preparedness. Most of the larger cities have received training and equipment from the U.S. Department of Defense or the U.S. Department of Justice, some have received grants and training from the Centers for Disease Control and Prevention (CDC), and all have spent time and money from state and local budgets. The MMRS program’s emphasis on multiagency, multijurisdictional planning undoubtedly played a major role in increasing preparedness in many cities, but no large city could become well prepared solely as a result of the relatively meager funding provided by the OEP contracts.

The remainder of this chapter describes a three-element evaluation procedure built upon these principles. The three elements are review of written documents and data, a site visit by a team of peer reviewers, and observations at exercises and drills. The three procedures are complementary means of analyzing the community’s response capabilities, and the next two sections focus on first identifying a subset of essential capabilities and then specifying preparedness criteria for each. The chapter con-

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

cludes by proposing some specific procedures for gathering data at exercises and drills and at site visits.

ESSENTIAL RESPONSE CAPABILITIES

As noted above, the committee’s Phase I report (Institute of Medicine, 2001) identified nearly 500 potential indicators of preparedness (see Appendix E). Chapter 6 provides information on how and why the committee arrived at these indicators, suggests that no evaluation would be likely to use all of the defined indicators, and proposes a means of beginning the selection problem, namely, to look first for output measures and to rely on process and input measures only when corresponding outputs are unavailable. This approach greatly reduces the number of potential items to be included in an evaluation effort, but the evaluator is still left with a large number of items. The committee has made further reductions by analyzing the critical actions required for effective responses to large-scale CBR terrorism incidents, that is, the essential response capabilities.

The specific characteristics and importance of these essential response capabilities vary with the type of agent and the other details of the incident, as do the relative importance of the various capabilities, but the many elements on the list of MMRS program contract deliverables and the corresponding preparedness indicators can be integrated into a list of 23 essential functions. They are listed below in the order in which they would generally become necessary:

  1. Relationship development (Communication, coordination, and control are especially critical in responding to events like those of the autumn of 2001)

    • city agencies, state and other local governments

    • federal agencies and local federal facilities

    • private institutions, especially health care institutions

    • voluntary community organizations (e.g., Red Cross, churches, ham radio operators)

  1. Communication system development

    • telephonic, computer, and radio hardware; points of contact; procedures

    • alternatives to commercial services, which are likely to be overwhelmed during a terrorist event.

    • mutual aid pacts with nearby communities address compatible communication equipment

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
  1. Hazard assessment

    • high-risk sites identified and contingency plans developed (although OEP asks for plans for coping with 1000 victims of a chemical attack and 3 levels of biological attack, each community should use this assessment to make estimates of likely casualty volumes specific to the area and situation).

  1. Training

    • awareness, equipment, treatment, exercises

    • fire and police departments, emergency medical technicians, emergency services and public health personnel, hospitals, individual medical care providers

  1. Equipment and supplies

    • purchase and maintenance (general purpose as well as specialized for CBR agents)

    • reception and distribution of “push package” from CDC

  1. Mass immunization and prophylaxis

  2. Addressing the information needs of the public and the news media (Experience from September 11 and the anthrax incidents emphasizes the importance of early and frequent communication with the public through a single authoritative spokesperson on health matters.)

  3. First responder protection

  4. Rescue and stabilization of victims

  5. Diagnosis and agent identification

    • hardware and software to monitor health trends in close to real time

  1. Decontamination of victims (at site of exposure or at a hospital or treatment site)

  2. Transportation of victims

    • from incident site to hospital or casualty collection point

    • from hospital to hospital (including use of National Disaster Medical System [NDMS])

    • patient tracking system

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
  1. Distribution of supplies, equipment, and pharmaceuticals

    • from local cache

    • from National Pharmaceutical Stockpile

  1. Shelter and feeding of evacuated and displaced persons

    • provisions for emergency shelter for persons fleeing sites of perceived danger

  1. Definitive medical care

    • trained personnel, beds, supplies and equipment

    • locations, in event that existing hospitals’ capacities are inadequate

    • mass immunization or distribution of drugs or vaccines

  1. Mental health services for responders, victims, caregivers, and their families

  2. Volunteer utilization and control

  3. Crowd and traffic control

    • at and near facilities rendering emergency medical care

    • at hospitals or facilities dispensing medication

    • along evacuation routes

  1. Evacuation and quarantine decisions and operations

  2. Fatality management

    • large numbers of contaminated or infectious corpses

  1. Environmental cleanup, physical restoration of facilities, and certification of safety

  2. Follow-up study of responder, caregiver, and victim health

  3. Process for continuous evaluation of needs and resources, during and after exercises and actual CBR, mass-casualty, and hazardous material (hazmat) events and disease outbreaks

With these 23 essential functions or capabilities as a guide, selection of a set of preparedness indicators for evaluation is considerably easier. The committee believes that the set of indicators described in the following section can serve as a suitable proxy for preparedness. Evaluating even this limited set of indicators nevertheless demands evaluators or auditors

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

with diverse backgrounds and expertise in a variety of areas as well as several auditing techniques. The approach taken by the committee calls for a combination of evaluation of documents submitted to OEP by the community to be evaluated, on-site questioning by a site-visit team, and direct observation of drills and exercises.

PREPAREDNESS INDICATORS FOR EVALUATION OF WRITTEN SUBMISSIONS, ON-SITE INSPECTION, AND OBSERVED EXERCISES

Table 8-1 shows a list of preparedness indicators selected from the tables of Appendix E that cover the 23 essential MMRS capabilities outlined in the previous section. In accordance with the philosophy expressed at the beginning of this chapter, the committee sought to keep the number of indicators requiring on-site interviews or observations to a manageable number by selecting a number of indicators that involved documents or other written records that could be mailed or otherwise sent to the evaluators. For many essential capabilities, such written records were the optimal or only feasible indicators; in other cases, selection of a written evaluation rather than an on-site evaluation was a compromise between the optimal measure and the realities of time and expense for both the assessor and the assessed. As suggested in Chapter 6, the committee considers output indicators more likely to be valid than process and input indicators, and Table 8-1 therefore heavily favors output indicators for on-site evaluations. Should any of the listed output indicators be unavailable, the committee expects the evaluator to use the corresponding process or input indicators to guide a judgment about preparedness.

PREPAREDNESS CRITERIA

No generally agreed-upon model for local preparedness exists, nor are good data or even a solid consensus available about what constitutes acceptable objective evidence of capability for most of the preparedness indicators listed above. The committee is also sensitive to the great diversity of circumstances facing the nation’s cities and the variety of ways in which they are organized to respond to emergencies. The committee therefore chose not to try to specify rigid standards for each of the countless possible combinations of incident types and response approaches. Instead, the proposed assessment program puts considerable faith in the judgment of what is now a relatively small but rapidly growing cadre of individuals who have been in the forefront of responding to and planning for responses to incidents related to the use of CBR agents. Nevertheless, to ensure the comparabilities of the assessments made by different evalu-

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

ators and to provide communities with some indication of what those experts will be looking for, the committee has assembled below, for each of the essential capabilities listed in Table 8-1, criteria that should serve as the core of evaluators’ judgments about preparedness. Armed with these criteria, it should be possible for an evaluator or a team of evaluators to determine whether a community is well prepared, prepared, or poorly prepared in each of the 23 essential capabilities. The committee feels strongly that the real value in the proposed evaluation system lies in identifying capabilities in need of improvement, and has therefore resisted the temptation to specify a passing grade. The fact is that, as noted on page113, preparedness as an abstract concept is meaningless. That is, even a perfect score on each of the 23 capabilities will not guarantee an optimal response to all imaginable CBR events; less than a perfect score makes it easy to imagine an event that will be handled poorly.

1.
Relationship Development (Partnering)
Preparedness Indicator

Documentation of effective coordination in an exercise or an actual incident with or without CBR agents.

  • The lead agency provides written documentation of an MMRS-wide response system that includes management, operations, logistics, planning and intelligence, and finance and administration activities.

  • The lead agency provides a list of community-level response plans used regularly for non-terrorist-related emergencies or disasters, for example:

    • Emergency Operations Plan

    • Multiple Casualty Incident Plan

    • Hazmat Response Plan

    • Emergency Medical Service (EMS) Management Plan

  • The lead agency provides an after-action report from a full-scale exercise, which should be conducted at least once every 3 years.

  • The lead agency documents actual events, including evaluation of potential for terrorism by the incident commander.

Preparedness Indicator

Evidence from exercises or actual events demonstrating workable interface among local plans.

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

TABLE 8-1 Preparedness Indicators and Mode of Evaluation of MMRS Plan Elements Relevant to Each of 23 Essential Capabilities

Essential Capability

MMRS Plan Element

1. Relationship development (partnering)

2.02 Description of how responses to a CBR terrorism incident by public safety, public health, and health services sectors will be coordinated

 

3.04 Coordination with other political, mutual-aid, or other MMRS program jurisdictions

2 Communication system development

3.07 Detailed notification and alert procedures via redundant systems

 

 

 

 

 

3.09 Provisions for accurate and timely dissemination of information among MMRS members

 

8.01 Procedures for notification of hospitals, clinics, health maintenance organizations (HMOs), etc., that an incident has occurred

 

 

 

8.New 1 Procedures for recall of staff

 

 

3. Hazard assessment

2.New 1 Description of the planning environment (i.e., identification of local hazards, baseline strengths, vulnerabilities)

4. Training

3.20 A schedule for exercises

 

9.01 Training requirements for all personnel responding to the scene of an incident or providing care to victims of a CBR agent-related incident

 

 

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Preparedness Indicator

Written

Site Visit

Drill

Documentation of effective coordination in an exercise or an actual incident with or without CBR agents

X

 

X

Evidence from exercises or actual events demonstrating workable interface among local plans

X

X

X

• Documented success by regular testing or during actual use in an emergency

X

 

X

• System is not dependent on commercial services alone.

X

X

 

• Mutual aid agreements with surrounding communities insure interoperability of key communication systems

X

 

 

Demonstration of effective use of all systems in periods of peak demand through unannounced tests or use in an actual emergency

X

 

X

• Percentage of facilities contacted in 1 hour during weekly notification checks

X

 

 

• Time from initial contact to initiation of hospital disaster plan or incident command system

X

 

X

• Calls to random sample of list demonstrate that list is up to date

 

X

 

• Percentage of staff returning calls in 2 hours

X

 

X

A communitywide assessment identifies strengths, barriers and challenges, and a priority list for planning efforts

X

 

 

Collection of after-action reports

X

 

 

• Demonstration of knowledge of subject matter to peer reviewer by selected sample of trained personnel from any level of any participating organizations or through functional drills, communitywide exercises, or responses to actual CBR agent, hazmat, or infectious disease outbreak events

 

X

X

• Certification or other nationally recognized affirmation of CBR agent-specific knowledge and skills, if such means for certification become available in the future

X

 

 

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Essential Capability

MMRS Plan Element

5. Equipment and supplies

10.02 Quantities of pharmaceuticals sufficient to care for 1,000 victims of a chemical agent and for entire affected population for 24 hours after a biological incident

10.04 Detailed procedures for equipment maintenance and pharmaceutical storage

 

 

 

 

 

 

 

 

6 Mass immunization or prophylaxis

7.05 New plans or augmentation of existing plans for management and implementation of a mass immunization or prophylaxis plan

 

 

 

 

7. Attention to the information needs of the public and the news media

3.08 Detailed management procedures for public affairs

 

 

 

 

8. First responder protection

5.11 Procedures for procurement and provision of appropriate equipment and supplies

8.05 Availability of adequate personal protective equipment for hospital and clinic providers

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Preparedness Indicator

Written

Site Visit

Drill

Availability of all required antidotes, antibiotics, and immune sera, in appropriate quantities, for inspection by site-visit team or peer reviewer

 

X

 

• Evidence that the mechanism of delivery and storage is secure in natural disasters, mock drills, earthquakes, or hazmat events

 

X

 

• Consistency of inventory with records of pharmacy and therapeutics committee meetings

X

 

 

• Knowledge of procedures for return of unused supplies and decontamination of equipment by logistics personnel

 

X

 

• Evidence that a sample of equipment selected by peer reviewer is in working order

 

X

 

• Performance of required maintenance and/or prompt retrieval of maintenance manual by logistics personnel when queried by peer reviewer

 

X

 

• After-action report detailing successful response to a CBR incident (real or a hoax), a natural outbreak of disease (e.g., a meningitis or influenza vaccination campaign or an outbreak of rabies or giardiasis), or a large-scale exercise

X

 

 

• Identification in the plan of distribution sites and required personnel

X

 

 

• Percentage of responder and caregiving personnel immunized if the plan calls for prophylactic immunizations

X

 

 

• A knowledgeable and credible spokesperson has been designated to provide health information to the public in the event of a terrorist attack with a CBR agent.

X

 

 

• Collection of finished communiqués

X

 

 

• Documented use of media packages in CBR agent-related hoaxes or incidents or other hazmat-related or epidemic events

X

 

 

Demonstration that the appropriate types and quantities of equipment and supplies have been purchased and are readily accessible

 

X

X

Demonstration of competency with equipment (e.g., by a respirator fit test) for expert peer reviewer

 

X

X

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Essential Capability

MMRS Plan Element

9. Rescue and stabilization of victims

5.03 Detailed procedures for extraction of victims from event site

 

5.04 Detailed procedures for administration of appropriate antidote

 

5.06 Procedures for victim triage and initial care before transport to definitive medical care facility

 

8.03 Provisions for the capability of local health care facilities to provide triage and initiate definitive care

 

 

10. Diagnosis and agent identification

5.02 Detailed procedures for detection and identification of agents

 

7.03 Identification of early-warning indicators that will be used to alert local officials of a bioterrorism event

 

 

 

 

 

8.07 Ability of medical staff to recognize and treat casualties caused by CBR agents

 

 

11. Decontamination of victims

5.05 Detailed procedures for decontamination of victims

 

 

 

5.09 Procedures for management of patients arriving at hospitals without prior field screening or decontamination

 

 

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Preparedness Indicator

Written

Site Visit

Drill

Hands-on demonstration (for peer reviewer or in a large-scale drill or actual hazmat incident) of safe and efficient extraction of a victim from a contaminated area

 

X

X

Hands-on demonstration (for peer reviewer or in a large-scale drill or actual hazmat incident) of administration of proper antidote

 

X

X

Hands-on demonstration (for peer reviewer or in a large-scale drill or actual hazmat incident) of victim triage and initial care

 

X

X

• Numbers, types, and durations of diversions in previous 3 months

X

 

 

• Numbers and types of patients transferred out of the hospital to other facilities in previous 3 months

X

 

 

Hands-on demonstration (for peer reviewer or in a large-scale drill or actual hazmat incident) of agent detection and identification

 

X

X

• Demonstration of appropriate use of early-warning indicators in peer-review interview, exercise, or actual event

 

X

X

• Percentage of laboratory personnel certified by relevant professional organization

X

 

 

• Demonstration to peer reviewer of knowledge and availability of supplies to carry out specified assays or successful detection of a test sample containing a close relative of the designated agents

 

X

X

• Laboratory quality assurance test results

X

 

 

• Demonstration of knowledge in responses to peer reviewer questions, exercise, or actual event

 

X

X

• Hands-on demonstration (for peer reviewer or in a large-scale drill or actual hazmat incident) of decontamination of victims

 

X

X

• List of all required equipment on hand or readily accessible

X

 

 

• Actual decontamination of individual patients

X

 

 

• Successful decontamination of multiple patients in an exercise or actual hazmat event

X

 

X

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Essential Capability

MMRS Plan Element

 

8.02 Procedures for protection of hospitals, clinics, and HMOs from contamination from environmental or patient sources (lockdown procedures)

 

 

 

 

 

 

 

 

 

 

12. Transportation of victims

3.11 Provisions for control of transportation assets, medical and nonmedical

 

5.07 Provisions for emergency medical transportation of victims

 

4.01 Detailed procedures for preparation of patients for movement to other areas of the region or nation

 

 

13. Distribution of supplies, equipment, and pharmaceuticals

10.New 1 Procedures for distributing pharmaceuticals and equipment to local personnel and facilities

 

10.New 2 Procedures for requesting, receiving, and distributing pharmaceuticals from the National Pharmaceutical Stockpile (NPS)

 

8.New 2 Procedures for delivery of nonmedical supplies

 

 

 

 

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Preparedness Indicator

Written

Site Visit

Drill

• Numbers of secondary infections of staff or other patients in prior 6 months

X

 

 

• Current conversion rate for positive tuberculosis (purified protein derivative) skin tests among staff

X

 

 

• Numbers of negative-pressure isolation rooms available, overall and in emergency departments (EDs)

X

 

 

• Numbers of tuberculosis, rubella, or varicella patients admitted to nonisolation rooms in prior 6 months

X

 

 

• Numbers of staff furloughed due to exposure to patients with varicella, rubella, or other infectious diseases in prior 6 months

X

 

 

• For the most recent tuberculosis patient, the time from examination to the time of isolation

X

 

 

Availability of anticipated assets on short notice for random check, planned exercise, or actual emergency

X

 

X

Availability and response times in exercises or actual mass-casualty events

X

 

X

• Awareness of plan and procedures and when and how to initiate them by emergency medical services and hospital officials

 

X

 

• Evidence of NDMS support for MMRS program plan and procedures for activation

X

 

X

Evidence from drill, actual event, or questioning by expert peer reviewer that local distribution of MMRS program pharmaceuticals and equipment will be rapid enough to maintain local supplies for at least the initial 24 hours of an event

X

X

X

Evidence from drill, actual event, or questioning by expert peer reviewer that local distribution of NPS supplies (push packages and vender-managed inventory) will be rapid enough to maintain local supplies after initial 24 hours of an event

X

X

X

• No disruption of services due to shortages during a drill or mass-casualty event

X

 

X

• Response times for deliveries

X

 

 

• Demonstration that an alternative supplier has necessary quantities or can deliver them in 24 hours

X

X

 

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Essential Capability

MMRS Plan Element

14. Shelter and feeding of evacuated and displaced persons

Not addressed in contracts

 

 

15. Definitive medical care

3.12 Detailed procedures for the management and augmentation of medical personnel

 

8.01 Procedures for notification of hospitals, clinics, HMOs, etc., that an incident has occurred

 

 

 

 

 

8.06 Local availability of adequate pharmaceuticals and equipment (ventilators) or plans to obtain them in a timely manner

 

 

 

 

 

8.07 Ability of medical staff to recognize and treat casualties caused by CBR agents

 

 

 

 

 

 

 

 

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Preparedness Indicator

Written

Site Visit

Drill

• Demonstration that a lead agency responsible for evacuee shelter and feeding has been identified and has been demonstrated to have effective working relationships with leadership for fire and police departments, public health agencies, emergency management agencies, and other voluntary agencies that provide evacuee shelter and feeding (e.g., demonstration that the local chapter of the American Red Cross has a working relationship with the Salvation Army)

X

 

X

• Demonstration that the lead agency’s disaster plan reflects special standard operating procedures for sheltering evacuees of CBR agent-related incidents

X

 

 

Demonstration of effective use of all communication systems, at multiple sites and for several types of medical personnel, in periods of peak demand, through unannounced tests or use in an actual emergency (snowstorm, hurricane, etc.)

X

 

 

• Documented resolution of any issues related to cross-jurisdictional licensure and liability coverage

X

 

X

• Percentage of facilities contacted in 1 hour during weekly notification checks

X

 

 

• Time from initial contact to initiation of hospital disaster plan or incident command system

X

X

X

• Availability of all essential antidotes, antibiotics, in them and immune sera, in appropriate quantities, for inspection by site-visit team or peer reviewer

 

X

 

• Evidence of effective collaboration in coping with recent national shortages of influenza and tetanus vaccines and gamma globulin and shortages of antibiotics during emergencies

X

 

 

• Response time to retrieve requested items in drills or in actual cases

X

 

X

• Laboratory quality assurance test results

X

 

 

• Demonstration of knowledge in responses to peer-reviewer questions, exercise, or actual event

 

X

X

• Certification or other nationally recognized affirmation of CBR agent-specific knowledge and skills, if such means for certification become available in the future

X

 

 

• Time from examination of tuberculosis patients to isolation

X

 

 

• Number and type of negative-pressure isolation rooms available in EDs and in total

X

X

 

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Essential Capability

MMRS Plan Element

16 Mental health services for responders, victims, caregivers, and their families

3.22 Designation of mental health care for emergency workers, victims and their families, and others in community needing special assistance

17. Volunteer utilization and control

Not addressed in contracts

 

 

 

 

 

 

1.8 Crowd and traffic control

3.18 Provisions for crowd control

 

 

 

 

 

3.19 Provisions for protection of treatment facilities and personnel

19 Evacuation and quarantine decisions, operations

Not addressed in contracts

 

 

 

 

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Preparedness Indicator

Written

Site Visit

Drill

After-action reports from other kinds of disasters or exercises that document coordination, availability, use, and effectiveness of mental health professionals

X

 

 

• Demonstration that the lead voluntary agency maintains inventory of trained volunteers for mental and physical health, family services, and other purposes

X

 

 

• Demonstration that the lead voluntary agency responds to disaster events within 2 hours of notification; this response includes shelter, feeding, disaster-related health services, disaster-related mental health services, damage assessment, and family services, as appropriate.

X

 

 

• Demonstration that “spontaneous” volunteers are effectively screened, oriented and trained, given identification, and deployed

X

 

 

• Demonstration that the language and the demography and culture of the communities that the volunteers serve are kept in mind when the volunteers are selected and trained

 

X

 

• Demonstration that an established plan provides for crowd control at special events or during civil disturbances

X

 

 

• Demonstration that officers receive regular training for these responsibilities

X

 

 

• Demonstration that adequate protective equipment is available for police officers

X

 

 

After-action reports that document crowd and traffic control at events with large attendances such as sporting events, concerts, and political conventions and/or in prior natural or technological disasters

X

 

 

• Written plan that includes procedures for deciding upon and conducting public safety measures such as shelter in place, orderly evacuation, quarantine of individuals and geographical areas, and isolation of patients or groups of patients.

X

 

 

• Demonstration that the identified leadership can verbalize the contents of the procedure to evacuate a contaminated facility

 

X

 

• Demonstration that the identified leadership can verbalize the contents of the procedure to initiate isolation or quarantine

 

X

 

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Essential Capability

MMRS Plan Element

20. Fatality management

7.10 Procedures for augmentation of morgue facilities and staff

 

 

 

7.11 Procedures for decontamination or isolation of human remains

21. Environmental cleanup, physical restoration of facilities, and certification of safety

7.12 Procedures for identification of environmental risk and determination of the need for decontamination or vector intervention

 

7.13 A process for safe reentry into the affected area in consultation with local, state, and federal environmental agencies

22. Follow-up study of responder, caregiver, and victim health

Not addressed in contract

23. Process for continuous evaluation of needs and resources

3.21 Assignment of responsibility for after-action reports and addressing report findings

 

 

 

 

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Preparedness Indicator

Written

Site Visit

Drill

• Contingency contracts or other arrangements for storage capacity with local hospital morgues, mortuaries, warehouses, other facilities with cold-storage capabilities, and sources of refrigerated trucks

X

 

 

• Evidence of NDMS support and procedures for activation (joint training, tabletop demonstration of interface with Disaster Mortuary Operational Response Teams)

X

 

 

• Hands-on demonstration of decontamination in an exercise or actual incident

 

 

X

• Evidence that standard operating procedures are available at morgue facilities in sufficient quantity to distribute to any expedient sites and that required personnel is available

 

X

 

Demonstration of an effective process to expert peer reviewer; in response to questioning or by performance in an exercise, actual hazmat event, or disease outbreak

 

X

X

Same as above for MMRS Plan Element 7.12

 

 

 

Demonstration that the response plan includes practical process for scientific investigation of human health effects in responders, caregivers, and victims, and evidence that baseline data on employees are available

X

 

 

• Possession by all participating agencies and institutions of a collection of after-action reports

 

X

 

• During-action reports from extended exercises or prolonged responses to actual CBR agent or hazmat events

X

 

 

• Evidence for changes in structure or functioning in response to deficiencies identified in after-action or during-action reports

X

 

 

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
  • A legally constituted mutual-aid plan includes members of all professions participating in the MMRS.

  • The lead agency documents mutual aid during actual events that involve the community’s personnel (non-terrorist-related or routine events).

  • The lead agency provides a plan for receiving outside assistance from the coroner or medical examiner, hospitals, and the public health department (this may include a state-level mutual-aid plan, preidentified federal resource, or professional organization-based plans).

2.
Communication System Development
Preparedness Indicator

Documented success of notification and alert procedures by regular testing or during actual use in an emergency.

  • A notification plan provides an immediate alert to all agencies, hospitals, and other entities with an essential or important role in MMRS response.

  • An activity log shows that testing is being conducted at least weekly and at random times, including nights and weekends.

  • An activity log shows an 80 percent response rate during testing (at least weekly) or during an actual emergency.

Preparedness Indicator

Demonstration of accurate and timely dissemination of information among MMRS members by all communications systems in periods of peak demand through unannounced tests or use in an actual emergency.

  • The lead agency demonstrates the availability of a system that disseminates timely (within minutes) information to MMRS members.

  • An activity log demonstrates regular use of the notification system for information dissemination for weather and other recurring events (for example, diversion of patients to other hospitals or hospital closures).

  • An activity log shows an 80 percent response rate, confirming receipt of information by recipients.

  • The lead agency provides evidence that two-way communications are in place, for example, that hospitals are reporting ED closures, with the compiled data being distributed back to hospitals in near real time.

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
Preparedness Indicator

System is not dependent on commercial services alone.

Preparedness Indicator

Mutual aid agreements with surrounding communities insure interoperability of key communication systems (compatible hardware, common radio frequencies, cross-training)

Preparedness Indicator

Time from initial contact to initiation of hospital disaster plan or incident command system.

  • One or more hospitals demonstrate that operational incident management is in place within 20 minutes of notification.

  • One or more hospitals demonstrate that hospital emergency operations are being implemented at the operational level (operational personnel are implementing their assignments) within 5 minutes of notification.

3.
Hazard Assessment
Preparedness Indicator

A communitywide assessment identifies strengths, barriers and challenges, and a priority list for planning efforts.

  • Sources of information are reported and appropriate (i.e., what is basis of preparation?).

  • All relevant institutions (health officers, laboratory personnel, hazmat personnel, etc.) have participated in the assessment.

  • Criteria for prioritization are explicit (e.g., is a high likelihood of occurrence or an event with a large impact weighted more heavily?).

  • A variety of potential CBR scenarios have been considered.

  • The rationale for the assets needed to respond to different hazards is explicit and reasonable.

  • Estimates of potential numbers of casualties have been related to types and circumstances of hazard exposure.

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
4.
Training
Preparedness Indicator

A collection of after-action reports documents a program of drills and exercises.

  • Tabletop exercises should be performed with senior police and fire personnel at least every 3 years.

  • A full-scale MMRS-wide exercise should be conducted at least every 3 years.

Preparedness Indicator

Demonstration of knowledge of subject matter by MMRS personnel from several levels and several organizations (also, see the discussion of preparedness indicators under the elements Diagnosis and Agent Identification and Definitive Medical Care below).

  • Eighty percent of selected MMRS personnel correctly answer at least 80 percent of questions on a multiple-choice test of recognition indicators and response precautions for a terrorist event.

  • Terrorism awareness training is provided in police and fire academy training.

  • Hazmat training for retention of certification is provided for all hazmat team members.

  • Refresher training in CBR agent recognition and response is given to all police, fire, EMS, and Office of Emergency Services personnel at least every 3 years.

  • Command training (at the fire chief or police captain academy) includes a terrorism element (this can also be done through a tabletop exercise).

5.
Equipment and Supplies
Preparedness Indicator

Availability of all required antidotes, antibiotics, and immune sera, in appropriate quantities, for inspection by site-visit team or peer reviewer.

  • An inventory lists all pharmaceuticals required by MMRS medical protocols.

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
  • Calculations or mathematical models for estimating the needs of the region’s population are available.

  • The property officer can demonstrate updating of the system by analysis of the entire stock.

  • The property officer can demonstrate the mechanism used to analyze the stock at other supply sites.

  • Written protocols cover the movement of materials from site to site.

  • Links to central resources (from the state or CDC) for supplies such as immune sera (e.g., botulinum antitoxin) and variola virus vaccine or immunoglobulin can be demonstrated.

Preparedness Indicator

Evidence that the mechanism of delivery and storage is secure in natural disasters, mock drills, earthquakes, or hazmat events.

  • Supplies are available at more than a single storage site.

  • Records of controlled drugs are complete and up to date.

  • Storage site personnel are familiar with procedures for the release of supplies and equipment and the documentation of their release.

Preparedness Indicator

The inventory is consistent with the records of the pharmacy and therapeutics committee meetings.

Preparedness Indicator

Logistics personnel are familiar with procedures for the return of unused supplies and decontamination of equipment for restorage and reuse.

Preparedness Indicator

Demonstration that a sample of equipment selected by the peer reviewer is in working order.

Preparedness Indicator

Performance of required maintenance or prompt retrieval of maintenance manual by logistics personnel when queried by the peer reviewer.

  • A biomedical engineer has checked equipment upon its receipt.

  • User operation and maintenance training has been conducted if the equipment is not similar to or compatible with that used in the local hospitals and by EMSs.

  • The maintenance log is available and up to date.

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
6.
Mass Immunization and Prophylaxis
Preparedness Indicator

An after-action report detailing a successful response to a natural outbreak of disease, an incident (real or a hoax) involving a CBR agent, or a large-scale exercise. The report includes the following:

  • the method by which the index case was identified;

  • the time frame between onset and identification of the agent involved;

  • verification of reporting of the agent involved to the local public health system,

  • a chronology of the investigation;

  • the identification of the professionals and agencies involved;

  • the roles and responsibilities of the professionals and agencies involved; and

  • a summary of the activity, the actions taken, and recommendations for improvement.

Preparedness Indicator

A plan that identifies distribution sites and required personnel, that recognizes the importance of essential public safety personnel and health care providers, and that encompasses site security and record keeping.

  • The community has a well-defined public immunization effort through the local health department, hospital, or community collaborative.

  • The responsible entity can identify the percentage of all immunizations given in the community that are provided through the public program.

  • The responsible entity has a record-keeping system that identifies community providers who administer vaccines received through the public health system to low-income patients.

  • An electronic immunization registry that includes public and private vaccine providers is in place.

Preparedness Indicator

The percentage of responder and caregiving personnel who have been immunized if the plan calls for prophylactic immunizations.

  • The lead agency can document that at least 80 percent of designated personnel have been immunized.

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
7.
Attention to the Information Needs of the Public and the News Media
Preparedness Indicator

A knowledgeable and credible spokesperson has been designated to provide health information to the public in the event of a terrorist attack with a CBR agent.

Preparedness Indicator

A collection of finished communiqués.

  • Basic press releases on chemical and biological threat agents are readily accessible in paper and electronic formats and in languages other than English if necessary to meet community needs.

  • An Emergency Public Information plan applicable to all hazards is written.

  • Trained public information officers with 24-hour call-back and contact information have been designated.

  • All public information officers have basic awareness of issues related to terrorism.

  • Library of resources related to CBR agents are available for public information offices, for example, Jane’s Manual, the green book and the blue or red book of the U.S. Department of Defense or similar publications, articles from the Journal of the American Medical Association, websites, and other reference books.

  • A media contact list is preloaded onto a broadcast fax machine or computer and includes contacts for television, radio, print media, and non-English-language publications.

  • Emergency planners should anticipate the need to provide accurate information to victims’ families through Web sites and patient locator systems that are created in advance and activated immediately following a catastrophic event.

Preparedness Indicator

Documented use of media packages in CBR agent-related hoaxes or incidents, other hazmat events, or disease outbreaks.

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
8.
First Responder Protection
Preparedness Indicator

Appropriate types and quantities of personal protective equipment and supplies have been purchased and are readily accessible to both traditional first responders and hospital and clinic staff.

  • The amounts and locations of the personal protective equipment that have been procured are consistent with the MMRS planning document’s presumed incident size and methodology for determination of equipment needs.

  • Inspection of at least two sites confirms the presence of the equipment specified in the inventory. Equipment should be readily accessible and clearly labeled at a site with appropriate temperature and humidity controls.

  • Emergency and security staffs have immediate access to personal protective equipment.

    • The equipment is stored in an area without a lock.

    • If the equipment is stored in a locked area, staff can locate the key without assistance.

  • On-duty personnel should be able to put on a breathing apparatus (e.g., masks or respirators) without coaching. Respiratory fit test (e.g., with banana oil or peppermint oil) should confirm that the breathing apparatus seals completely.

  • On-duty personnel should be able to put on chemical protective apparel without coaching. When suited, personnel should be heavily sprayed with water to show that the suit excludes outside elements (i.e., to show that no water penetrates the body suit).

9.
Rescue and Stabilization of Victims
Preparedness Indicator

Hands-on demonstration (for peer reviewer or in a large-scale drill or actual hazmat incident) of safe and efficient extraction of a victim from a contaminated area.

  • Appropriate level of personal protective equipment is correctly worn and maintained by all personnel while they are in areas that may be contaminated with a CBR agent (“hot” and “warm” zones).

  • Patients can be moved in a manner that is safe both for the patient

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

(e.g., spinal immobilization if the patient has received a trauma) and for the rescuer (e.g., the rescuer is able to correctly lift the patient with no compromise of his or her personal protective equipment).

Preparedness Indicator

Hands-on demonstration (for peer reviewer or in a large-scale drill or actual hazmat incident) of administration of proper antidote.

  • Antidotes are packaged for operational deployment.

  • Staff is able to deploy antidotes, distribute and administer antidotes in a timely fashion during a drill, or explain during a tabletop scenario how antidote distribution and administration would occur.

Preparedness Indicator

Hands-on demonstration (for peer reviewer or in a large-scale drill or actual hazmat incident) of victim triage and initial care.

  • Triage rules and any variations in mass-casualty situations are well understood by both prehospital emergency medical and ED personnel.

  • Data on numbers, types, and durations of ED diversions in previous 3 months demonstrate the consistent availability of emergency care for a wide variety of patients.

10.
Diagnosis and Agent Identification
Preparedness Indicator

Hands-on demonstration (for peer reviewer or in a large-scale drill or actual hazmat incident) of chemical agent detection and identification.

Preparedness Indicator

Demonstration of appropriate use of early-warning indicators of epidemic disease in a peer-review interview, exercise, or actual event.

  • Baseline data are available from a variety of sources.

  • A designated individual or office monitors data on a daily basis.

  • Decision rules and points of contact are available in the event of the discovery of unusual data points.

  • The communication network allows the rapid dissemination of information among health officers, clinical laboratories, health care facilities, and practitioners.

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
Preparedness Indicator

Demonstration to peer reviewer by laboratory personnel of knowledge and availability of supplies to carry out specified assays or successful detection of a test sample containing a close relative of the designated agents.

  • Laboratory quality assurance test results document capability to identify key CBR agents

  • Laboratory personnel are certified by the relevant professional organization.

Preparedness Indicator

Simulated patients presenting to two or three area EDs with signs and symptoms of smallpox are diagnosed accurately and are effectively isolated, ED and hospital infection control practices are effected immediately, appropriate staff and community officials are notified, and appropriate supportive care is arranged as needed. (Hospitals must be warned that simulated patients of some sort may be a part of the site visit.)

11.
Decontamination of Victims
Preparedness Indicator

Hands-on demonstration (for peer reviewer or in a large-scale drill or actual hazmat incident) of decontamination of victims at an incident site.

  • Review the MMRS plan to identify required decontamination equipment and bases for choice of type and quantity.

    • The equipment chosen is adequate to support decontamination of up to 1,000 victims of a terrorist incident involving chemical agents.

  • Inspection of at least one site confirms that the equipment is in inventory and is readily accessible.

    • The on-site inventory complies with the plan.

    • If the equipment is stored in a locked area, staff can locate the key without assistance.

  • The necessary equipment can be set up and functioning within 30 minutes of arrival on site.

    • Procedures are in place for expedient decontamination and keeping ambulatory victims on site for 30 minutes.

    • Equipment setup is not dependent solely on members of the hazmat unit.

    • The training required for both setup and operation has been pro-

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

vided to enough personnel to ensure the capability of equipment operation at all times (24 hours a day, 7 days a week, every day of the year).

  • Procedures and equipment will allow decontamination of at least 500 persons per hour.

    • An exercise processes mock ambulatory victims at a rate of at least 9 persons per minute.

  • Procedures are applicable in all weather and all seasons.

    • The available cover, heating, and clean dry clothing are sufficient to protect ambulatory victims against hypothermia.

Preparedness Indicator

Actual decontamination of individual patients arriving at hospitals without prior field screening or decontamination or successful decontamination of multiple patients in an exercise or actual hazmat event.

  • The decontamination system allows self-decontamination by ambulatory patients within minutes.

  • The lead agency provides evidence that security personnel and triage nurses at hospital entry areas have been trained to recognize potentially contaminated patients and to prevent their entry into the facility.

  • A drill provides evidence that multiple patients presenting simultaneously for decontamination can be adequately organized and managed (as determined by expert judgment).

  • An appropriate CBR agent simulant is completely removed during a full decontamination exercise.

Preparedness Indicator

Effective procedures are in place to inhibit transmission of infectious disease within hospitals, clinics, and other treatment sites.

  • No instance of secondary infections of staff or other patients in prior 6 months has been found.

  • No conversions to positive tuberculosis skin tests have been detected among staff in the prior 6 months.

  • Isolation rooms are available, in the ED and other departments.

  • No tuberculosis, rubella, or varicella patients have been admitted to nonisolation rooms in the prior 6 months.

  • No staff have been furloughed due to exposure to patients with varicella, rubella, or other infectious diseases in prior 6 months.

  • For the most recent tuberculosis patient, the time from the examination to patient isolation has been less than 1 hour.

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
12.
Transportation of Victims
Preparedness Indicator

List of available sources of vehicles and drivers for use in mass-casualty event, including those available through mutual-aid agreements, state agencies, and local federal facilities.

  • The lead agency provides current contracts and other agreements with public and private entities for emergency transport (buses, vans, and trucks).

  • The lead agency provides evidence of periodic communication with managers of anticipated transportation assets.

  • Standard operating procedures reflect state laws and local policies.

Preparedness Indicator

Interviews with one EMS contracted emergency medical transport provider, one noncontracted medical transport provider, and one nonmedical transport agency to confirm knowledge of MMRS plan, including the circumstances in which personal protective equipment and decontamination of patient transport vehicles are required and the means of acquiring both.

Preparedness Indicator

Availability of anticipated transportation assets on short notice for random check, planned exercise, or actual mass-casualty emergency.

Preparedness Indicator

Awareness of plan and procedures for movement of patients to other areas of the region or nation by EMS and hospital officials and when and how to initiate them.

  • Two hospital officials and an EMS official satisfy the site-visit interviewer if a previous exercise has not demonstrated knowledge of the MMRS plan and procedures.

  • The lead agency provides evidence of NDMS support for the MMRS plan and procedure for activation.

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
13.
Distribution of Supplies, Equipment, and Pharmaceuticals
Preparedness Indicator

Evidence from drill, actual event, or questioning by expert peer reviewer that local distribution of MMRS program pharmaceuticals and equipment will be rapid enough to maintain local supplies for at least the initial 24 hours of an event.

  • EMS and hospital systems understand the predetermined protocol in the plan for the distribution of pharmaceuticals, supplies, and equipment, including:

    • the quantity and type of supplies and equipment available,

    • the locations of the primary and secondary storage sites,

    • the need for 24-hour accessibility to all storage sites,

    • the priorities for distribution,

    • the person who has the authority to order and distribute supplies and equipment,

  • the means of transport of supplies and equipment to affected sites, and

  • the means by which trained staff at the affected sites are to receive and use the equipment.

Preparedness Indicator

Evidence from drill, actual event, or questioning by expert peer reviewer that local distribution of National Pharmaceutical Stockpile (NPS) supplies will be rapid enough to maintain local supplies after the initial 24 hours of an event.

  • EMS, hospital systems, and responsible local or state officials understand the predetermined plan for requesting, receiving, and distributing NPS supplies, whether they are from push packages or the vendor-maintained inventory, including:

    • the chain of command for requesting NPS supplies,

    • the quantity and type of pharmaceuticals available,

    • the plan for receiving NPS supplies and the availability of personnel to repackage NPS supplies for distribution to affected sites,

    • the transportation of NPS supplies to affected sites,

    • the distribution of NPS supplies to affected hospitals, and

    • the receipt and use of NPS supplies by appropriate personnel at the sites receiving the supplies.

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
Preparedness Indicator

No disruption of services due to shortages of nonmedical supplies during a drill or mass-casualty event.

  • The hospital emergency command center has access to a list of primary suppliers and alternative suppliers for the following: fuel and utilities, laundry, foodstuffs, water, waste removal.

    • If the list is maintained outside the command center, command center staff demonstrate the availability of a nontelephone communication system for the exchange of information.

    • If the list is maintained outside the command center, command center staff demonstrate the ability to access those with information outside the usual work hours from 9 a.m. to 5 p.m., Monday through Friday.

  • Hospitals can identify alternative hospital suppliers located within a 200-mile radius of the hospital. (Note that 200 miles is an arbitrary distance; an alternative distance could be selected, but the distance selected must allow delivery within 24 hours.)

  • Hospital logistics personnel are familiar with the procedures of the local police or sheriff department for allowing suppliers to enter “sealed” areas.

    • The police or sheriff department has an up-to-date list of primary and alternative hospital suppliers.

  • Hospitals have “standing emergency orders” with suppliers that the suppliers will automatically implement without contact from the hospitals.

    • Primary and alternative suppliers maintain at least a 48-hour inventory stock for normal demand.

14.
Shelter and Feeding of Evacuated and Displaced Individuals
Preparedness Indicator

The lead agency responsible for evacuee shelter and feeding has been identified and has demonstrated effective working relationships with leadership of the fire and police departments, public health agencies, emergency management agencies, and other voluntary agencies that provide evacuee shelter and feeding (e.g., the local chapter of the American Red Cross has a working relationship with the Salvation Army).

  • The agency demonstrates the capabilities to ensure the provision of food and shelter for its affected population and to ensure the feeding of emergency workers.

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
  • The lead agency demonstrates the capability to feed and shelter 10 percent of its affected population (assuming an affected population of 25,000 to 50,000 people) and all emergency workers.

  • The agency has an up-to-date list of buildings (e.g., schools) that have agreed to serve as shelters (as determined from an on-site review of documentation).

  • The agency can demonstrate how quickly during exercises shelters can be set up and other essential participants notified (as determined by questioning by the interviewer on site).

Preparedness Indicator

The lead agency’s disaster plan reflects special operating procedures for sheltering evacuees in scenarios involving CBR agents.

  • The plan describes where and how evacuees will be decontaminated if necessary before they enter shelters and who will do the decontamination.

  • The plan describes alternatives to sheltering evacuees if necessary because of a bioterrorist attack (infectious disease precautions).

15.
Definitive Medical Care
Preparedness Indicator

Demonstration of effective use of all systems for recall and augmentation of hospital staff, at multiple sites and for several types of medical personnel, in periods of peak demand, through an unannounced test or use in an actual emergency (e.g., snowstorm, hurricane, etc.).

  • The hospital demonstrates procedures for recall of employees and medical staff.

    • For a community that has experienced a major emergency, the hospital has activated an emergency recall plan and staff have responded.

    • The hospital has conducted an unannounced test of its recall syste m within the past year, and at least 80 percent of the staff whose response was requested responded within 2 hours

    • .The recall plan includes logistics and planning personnel (plant operations staff, support staff, etc.) as well as operations personnel (medical and nursing staff, etc).

  • The recall plan is functionally constructed so that it can occur in a timely fashion and provides adequate information for personnel to respond adequately.

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
  • Contact information is correct for at least four of five staff members in a test by or for site visitor.

  • The hospital has established and can provide written agreements with third-party agencies for augmentation of personnel.

  • All health care providers in the community have developed a coordinated plan for augmentation of personnel.

    • Minutes of a meeting showing that providers supplied information on augmentation plans and that duplications were identified and prioritized.

  • The hospital’s medical staff office has a list of all physicians in the community and their clinical privileges at other community hospitals.

Preparedness Indicator

Documented resolution of any issues related to cross-jurisdictional licensure and liability coverage.

  • The hospital has planned for liability coverage of volunteer physicians and nurses.

    • A “Good Samaritan” law absolving physician and nurse volunteers of liability except for gross negligence protects staff.

    • The hospital’s liability coverage includes a “Good Samaritan” provision.

Preparedness Indicator

Percentage of hospitals, clinics, HMOs, etc contacted in 1 hour during weekly notification checks of procedures for notification that a potential mass casualty incident has occurred.

  • A log indicates that weekly notification checks are being performed.

  • A log confirms that 80 percent of facilities were notified within 1 hour.

Preparedness Indicator

Time from initial notification to initiation of hospital disaster plan or incident command system.

  • Evidence shows that operational incident management is in place within 20 minutes of notification.

  • Evidence shows that hospital emergency operations are being

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

implemented at the operational level within 5 minutes of hospital notification (operational personnel are implementing their assignments).

Preparedness Indicator

Availability of all essential antidotes, antibiotics, and immune sera, in appropriate quantities, for inspection by site-visit team or peer reviewer.

  • Pharmacies at two or three hospitals have sufficient ciprofloxacin or doxycycline to start treatment or prophylaxis of 100 patients and a sufficient 2-pralidoxime (2-PAM) and atropine supply for 25 patients, as well as written protocols for obtaining more ciprofloxacin, 2-PAM, and atropine quickly.

  • Inventory lists include all pharmaceuticals required by the most current MMRS medical protocols.

  • The pharmacists visited know the locations, contents, and procedures for accessing the local MMRS cache.

  • ED staffs at two or three hospitals are able to demonstrate the protocol for securing within 24 hours 100 intensive care unit ventilators, of which at least 33 are appropriate for children.

  • The response time required to make available the appropriate antidotes or antibiotics for the hypothesized number of casualties has been tested.

  • Memoranda of understanding or other collaborative agreements with other local medical care facilities are available for the emergency loan and distribution of required equipment and pharmaceuticals, including pediatric ventilators.

Preparedness Indicator

Demonstration of knowledge of relevant treatment protocols by EDs, intensive care units, and primary care physicians and nurses in responses to peer-reviewer questions, exercise, or actual event.

  • The medical treatment protocols for patients affected by the agents specified in the MMRS program contract (nerve agents; blister agents; choking agents; blood agents; and those responsible for anthrax, botulism, hemorrhagic fever, plague, smallpox, and tularemia) are readily located by ED staff in two or three hospitals.

  • Health care professionals provide evidence of certification or other nationally recognized affirmation of CBR agent-specific knowledge and skills, if such means for certification become available in the future.

  • Simulated patients presenting to two or three area EDs with signs and symptoms of smallpox are diagnosed accurately and isolated effec-

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

tively, appropriate staff and community officials are notified, and appropriate supportive care is arranged as needed. (Hospitals must be warned that simulated patients of some sort may be a part of the site visit.)

  • For the most recent tuberculosis patient, the time from examination to the time of isolation was less than 1 hour.

  • Isolation rooms are available, in the ED and other departments.

  • No tuberculosis patients have been admitted to nonisolation rooms in previous 6 months.

  • No staff have been furloughed due to exposure to patients with varicella, rubella, or other infectious diseases in the previous 6 months.

16.
Mental Health Services for Responders, Victims, Caregivers, and Their Families
Preparedness Indicator

After-action reports from other kinds of disasters or exercises that document the coordination, availability, use, and effectiveness of mental health professionals.

Preparedness Indicator

Agreements with private organizations and individual practitioners to provide mental health services for all segments of the population.

  • Evidence of practitioner training or experience providing services to disaster victims and responders is available.

Preparedness Indicator

Written procedures for provision of on-scene and community support.

17.
Volunteer Utilization and Control
Preparedness Indicator

The lead voluntary agency maintains an inventory of trained volunteers for mental and physical health, family services, and other purposes.

  • The agency meets the following standards for a response to terrorist events:

    • The agency recruits and trains one disaster-related mental health worker and one disaster-related physical health services worker for every 200 individuals to be affected (minimum of 250 workers).

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
  • The agency recruits and trains up to five expert family services workers.

  • The response also includes public affairs and fund-raising activities in support of service delivery as a result of a disaster.

  • The agency is able to provide a list of active volunteers, how they were recently trained, and if and why they were recently activated.

Preparedness Indicator

The lead voluntary agency responds to disaster events within 2 hours of notification. This response includes shelter, feeding, disaster health services, disaster mental health services, damage assessment, and family services, as appropriate.

  • After-action reports from exercises or prior disaster events are provided.

  • CBR agent-related or other mass-casualty exercises are directly observed during an on-site visit.

Preparedness Indicator

“Spontaneous” volunteers are effectively screened, oriented and trained, given identification, and deployed.

  • Written policies and procedures address “vetting” of volunteers and their effective incorporation into community response efforts.

  • “Spontaneous” volunteers introduced into exercises and site-visit scenario-driven discussions are effectively incorporated into the community response.

  • Agreements have been established with all relevant agencies on needs for and use of volunteers.

Preparedness Indicator

Demonstration that the language and the demography and culture of the communities that the volunteers serve are kept in mind when the volunteers are selected and trained.

  • The agency has up-to-date language and demographic profiles of the communities that it serves and recruits and trains volunteer and paid staff to reflect those profiles.

  • At the request of the site visitor, the lead agency can contact health and family services workers with locally relevant non-English-language skills.

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
18.
Crowd and Traffic Control
Preparedness Indicator

After-action reports document crowd and traffic control at events with large attendances such as sporting events, concerts, and political conventions and prior natural or technological disasters.

  • In large cities the police handle large crowds and traffic control at events on a weekly basis. These include professional sporting events (e.g., football games, which 60,000 to 80,000 people attend; baseball games, which 25,000 to 50,000 people attend; basketball and hockey games, which 10,000 to 25,000 people attend); NASCAR races, which 100,000-plus people attend; as well as festivals, parades, and conventions. If there are no significant problems at the event, after-action activities most often involve a meeting in which key participants discuss things that could be improved for the next similar event.

Preparedness Indicator

An established plan provides for crowd control at special events and during civil disturbances.

  • The plan includes provisions for responsibility for incident command.

  • The plan addresses coordination between government and public utilities and among the various levels of government.

  • The plan includes provisions for the call-up of personnel and resource allocation.

    • Calls to a random sample show that telephone and page numbers are up to date.

    • The frequency of system tests is obtained.

    • The results of the most recent test are obtained.

  • The plan provides for the handling of mass arrests.

  • The plan provides for the handling of mass casualties.

  • The plan includes a security plan for potential treatment facilities and their personnel, including:

    • controlled access to the facility,

    • controlled access to the grounds,

    • traffic control measures, and

    • a clear definition of hospital security and police roles and responsibilities.

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
Preparedness Indicator

Officers receive regular training in crowd control.

  • Every officer should receive basic training in the police academy and then refresher training every 2 or 3 years. The training should cover, among other things:

    • expectations for various types of events,

    • crowd control measures,

    • understanding of the impact of deploying various chemical munitions, and

    • the use and testing of gas masks.

  • Other officers should receive more specialized training at a much greater frequency.

    • Many police agencies use “field force” techniques developed in Miami and Dade County, Florida, in the 1980s following several riots. These officers should receive initial training of 2 or 3 days and then refresher training at least once a year (in Charlotte, North Carolina, about 400 officers have received this training).

    • Special Weapons and Tactics (SWAT) teams should train every month to deal with armed and barricaded subjects and high-risk entries.

    • Any specialized team that would be called out during a situation involving a CBR agent should receive training and conduct exercises on a monthly basis.

  • Lesson plans, supporting procedural documents, attendance records documenting participation and proficiency, schedules for future training, and after-action reviews of exercises should all be available.

Preparedness Indicator

Adequate protective equipment is available for police officers.

  • Specialized teams that would be called out during a situation involving a CBR agent and that include police should be equipped with personal protective equipment ranging from level D to level A.

  • Depending on the community, one might see all officers with gas masks and helmets for use in riot control situations. Properly fitted gas masks might provide a minimal level of short-term protection against some hazards.

  • Field force officers should be fully equipped with crowd control gear, in addition to gas masks and helmets.

  • The “appropriate” level of protective gear for police officers not in a designated response role is difficult to establish. At a minimum, an

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

assessment has been made and action taken to provide whatever personal protective equipment that assessment supports.

19.
Evacuation and Quarantine Decisions and Operations
Preparedness Indicator

A written plan that includes procedures for deciding upon and implementing public safety measures such as providing shelter in place, conducting an orderly evacuation, quarantining of individuals and geographical areas, and isolating patients or groups of patients.

  • The plan does not need to be specific to CBR agent-related events.

  • Legal authority for the decision maker is established and documented in the plan.

  • Plans provide for the medical care of quarantined individuals.

  • Plans provide for the nonmedical care of quarantined or isolated individuals.

  • A written plan for the media includes prepared information and fact sheets explaining the need for and processes for the implementation of evacuation or quarantine.

Preparedness Indicator

Identified leadership can verbalize the contents of the procedure for the evacuation of a contaminated facility.

  • The responsible entity has reviewed the experience of the state, county, and city with the evacuation of facilities that have occurred during previous emergency or urgent conditions.

  • The evacuation plan has been practiced during disaster exercises (as evaluated by examination of after-action reports).

Preparedness Indicator

The identified leadership can verbalize the contents of the procedure for the initiation of isolation or quarantine.

  • The responsible entity has reviewed the experience of the state, county, and city with isolations or quarantines that have occurred during previous public health operations.

  • The isolation or quarantine plan has been practiced during disaster exercises (as evaluated by examination of after-action reports).

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
20.
Fatality Management
Preparedness Indicator

Contingency contracts or other arrangements for storage capacity with local hospital morgues, mortuaries, warehouses, other facilities with cold-storage capabilities, and sources of refrigerated trucks.

Preparedness Indicator

Evidence of NDMS support and procedures for activation.

  • The lead agency provides evidence of joint training or tabletop demonstration of interface with Disaster Mortuary Operational Response Teams.

Preparedness Indicator

Hands-on demonstration of decontamination can be provided in an exercise or actual incident.

  • The MMRS plan identifies required decontamination equipment and the basis for the choices of particular types and quantities of equipment.

    • The equipment chosen is adequate to support the decontamination of up to 1,000 victims of a terrorist incident involving chemical agents.

  • Inspection of at least one site confirms that the equipment is in inventory and is readily accessible.

    • The on-site inventory complies with the plan.

    • If the equipment is stored in a locked area, staff can locate the key without assistance.

  • The necessary equipment can be set up and functioning within 30 minutes of arrival on site.

    • Procedures for expedient decontamination and keeping ambulatory victims on site for 30 minutes are in place.

    • Equipment setup is not dependent solely on members of the hazmat unit.

    • Training required for both setup and operation has been provided to enough personnel to ensure the capability of equipment operation at all times (24 hours a day, 7 days a week, every day of the year).

Preparedness Indicator

Evidence that standard operating procedures are available at morgue fa-

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

cilities in sufficient quantity to distribute to any expedient sites and that the required personnel are available.

21.
Environmental Cleanup, Physical Restoration of Facilities, and Certification of Safety
Preparedness Indicator

Demonstration of an effective process for the identification of environmental risk and determination of the need for decontamination or vector intervention in response to questioning by the peer reviewer or by performance in an exercise, actual hazmat event, or disease outbreak.

  • Review of the MMRS plan shows that it includes provisions for determination of risk and the need for decontamination or vector intervention and patient treatment.

  • The agencies and organizations required to do the following tasks have been identified:

  1. determine the existence and nature of hazardous materials or the existence and nature of vectors,

  2. communicate findings to all MMRS response and management elements,

  3. communicate messages to the public, and iv. carry out long-term surveillance and cleanup of the affected area, as required.

  • Agreements are in place to secure additional (decontamination) response elements (personnel, supplies, and equipment).

  • A training and exercise program is available to support the system and protocols.

  • An on-site visit to a hazmat response team, an EMS unit, a hospital ED, or some other organization is made to observe the procedures and protocols used to identify environmental risk and determine the need for decontamination or vector intervention. A sample of personnel is able to

  • demonstrate the use of detection and agent identification equipment,

  • demonstrate the use of personal protective equipment, and

  • demonstrate use of a field management system for incorporation of specialty environmental resource agencies into the MMRS plan.

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
22.
Follow-up Study of Responder, Caregiver, and Victim Health
Preparedness Indicator

The response plan includes a practical process for scientific investigation of human health effects in responders, caregivers, and victims.

  • The local public health system has a written protocol for follow-up investigation of the human health effects (short term and long term), including the following:

    • an assessment of the nature and magnitude of the incident, including the agent(s) involved and the population affected;

    • a process for assessing the availability of resources, including the appropriate personnel, equipment, budget, treatment, and laboratory capacities;

    • baseline health data on designated emergency response personnel;

    • the identification of the “study” population and a control population, if appropriate; and

    • a communications strategy for reporting the process and results of the study to the community.

23.
Process for Continuous Evaluation of Needs and Resources
Preparedness Indicator

Possession of a collection of after-action reports by all participating agencies and institutions.

  • On-site indications that key agency participants have actually received after-action reports are available.

  • After-action reports for exercises and major events requiring emergency management are available. They should include, at a minimum:

    • a description of the exercise or incident,

    • the objectives of the exercise,

    • the roles played by various agencies and key individuals (public and private, both inside and outside the governmental unit preparing the report),

    • a list of problems or shortcomings encountered,

    • an assessment of the reasons that these problems or shortcomings occurred, and

    • an analysis of lessons for improved future performance.

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
  • In the absence of relevant after-action reports, written indications should assign responsibility for preparation of the reports to a particular agency or individual or should describe a procedure for assigning ad hoc responsibility in advance of planned exercises or immediately after the event for unplanned emergency management situations.

Preparedness Indicator
  • During-action reports from extended exercises or prolonged responses to actual CBR agent or hazmat events

  • On-site indications that key agency participants have actually received reports are available.

  • Reports should include, at a minimum:

  • a description of the exercise or incident,

  • the objectives of the exercise,

  • the roles played by various agencies and key individuals (public and private, both inside and outside the governmental unit preparing the report),

  • a list of problems or shortcomings encountered,

  • an assessment of the reasons that these problems or shortcomings occurred, and

  • an analysis of alterations in the community response required for meeting evolving needs.

  • In the absence of relevant during-action reports, written procedures should assign responsibility for preparation of the reports to a particular agency or individual or should describe a procedure for assigning ad hoc responsibility for monitoring planned exercises or unplanned emergency management situations for unanticipated developments.

Preparedness Indicator

Evidence for changes in structure or functioning in response to reported deficiencies.

  • A distribution list or lists for different types of after-action reports should be available so that findings can be disseminated to participants, supervisors, and policy officials.

  • A procedure for securing reviews of and comments on reports by other participants or close observers of the events covered should be in place.

  • At a minimum, these should be in writing.

  • For major exercises or events, provision should also be made for in-person discussions by key agency officials.

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
  • The lead agency provides files of written comments and minutes of meetings that discuss the findings, including evidence of agreement on steps taken in light of identified problems or shortcomings.

  • A procedure for generating and assigning responsibility for recommended steps to maintain or improve preparedness should be in place.

  • Procedures for assigning responsibility for subsequent follow-up should be in place to see whether the proposed steps have been taken or, if not, whether the problems or shortcomings have been addressed in another appropriate way.

  • Memos or meeting minutes indicating the following should also be available:

  • that subsequent follow-up of the steps has occurred and that any incomplete steps are still being monitored,

  • that substitute actions have been scheduled, or

  • that analysis of obstacles and a search for workable solutions are ongoing.

EXERCISES AND DRILLS

The committee members began their task with the common view that, in the absence of regularly occurring CBR terrorism incidents, the plans produced by MMRS program cities might be best evaluated by large-scale field exercises that would simulate such incidents and more specialized drills that would test the performances of specialized portions of the overall response plan. A proposal debated early in the committee’s discussions was to design an exercise(s) that would constitute a comprehensive test of each city’s response plan. The evaluation would then simply involve conducting the exercise and observing the response. This proposal was ultimately rejected as being too expensive in terms of the financial cost for OEP and in terms of time for local emergency response and medical personnel, difficult to tailor to 100 different locales, and in the case of a covert release of a biological agent, impossible to simulate realistically and ethically. Several members also observed that in their experiences it had been the planning rather than the conduct of exercises that was of greater value to the community.

One of the MMRS program contract deliverables in fact calls for a schedule of exercises, and another calls for the collection and distribution of after-action reports, so the committee opted to incorporate these exercises into the overall evaluation plan. Observers, preferably members of the team that will subsequently conduct a site visit to a community conducting an exercise, should attend large-scale exercises and significant drills before they plan a site visit. Despite the drawbacks mentioned in the previous paragraph, many of the essential capabilities can best be assessed

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

in this fashion, and some can only be assessed in this manner. Table 8-1 and the associated preparedness criteria can serve as guides for these observers, who should be required to produce written reports of their observations and judgments of preparedness for each of the essential capabilities with an X in the column of Table 8-1 labeled “Drill.” Given the expense and difficulty of planning and conducting a large scale exercise, OEP should also consider sharing these observations, suitably redacted to maintain security, with other MMRS program cities, perhaps by means of its password-limited website

SITE VISITS AND PEER EVALUATORS

Although the details of any site visit to some extent will be specific to the site being visited, the committee envisions a typical site visit consisting of a 3-day evaluation. The assessment team would gather on the afternoon or evening of Day 1 to meet, confirm assignments, and distribute the required materials. Day 2 would be devoted to individual interviews and observations, as would the morning of Day 3. Two scenario-driven group discussions would take place simultaneously on the afternoon of Day 3 (see below for more detail), and at least two assessment team members would attend each scenario. Debriefing of the team (i.e., when team members discuss their observations with each other) would take place on the morning of Day 4, and on the afternoon of Day 4, the team would debrief the community (i.e., provide some very general feedback on the team’s observations and conclusions). A formal report would be produced in the ensuing month by OEP staff or their representatives and would be based on the collective observations of the assessment team.

The assessment team should consist of five individuals collectively experienced in a variety of disciplines and professions. Their task is a broad one, and it is important that they be, and be perceived as, peers of the individuals being assessed. To this end the committee recommends that the team comprise a fire department representative familiar with hazmat operations; a city- or county-level emergency manager; a local public health officer familiar with surveillance systems; an individual with extensive managerial, operational, and clinical experience in the field of prehospital emergency medical services; and an acute-care medical practitioner, who could be a nurse or a physician, with clinical experience in infectious diseases or emergency medicine and mass-casualty operations. In practice, such a team would no doubt need one or two administrative support personnel. Consideration should also be given to including OEP’s regional Public Health Service emergency coordinator on the assessment team. This individual generally has served as the contracting officer’s technical representative for the MMRS program contract. Inclusion on the

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

team may produce a conflict of interest for the emergency coordinator, but he or she will also bring substantial important information regarding the local MMRS program. Similarly, the committee recommends that at least three of the five members have some previous involvement with the MMRS in their own community.

Both the community and the prospective site visitors should be notified at least six months in advance of the anticipated visit. This will allow both the community and the site visitors time to make necessary logistical arrangements, gather documents, and arrange schedules of likely participants. It will also allow OEP to gather necessary documents, review reports from previously observed exercise and drills in the community, and schedule some pre-visit training for the site visitors, which will be vital to insuring a consistent and valid assessment program.

Some pilot testing will be necessary to confirm the feasibility of this suggested approach, check interobserver reliability, and make changes where the committee’s suggestions cannot be implemented. In doing this pilot testing OEP should endeavor to include communities it has some reason to believe lie at of the extremes of the preparedness continuum. It seems unlikely that all MMRS communities are equally well prepared, despite OEP intentions, and an assessment program should at least be able to distinguish the extremes of systemic or societal preparedness.

Finally, it should be obvious that the assessment program being proposed here will entail considerable expense (comparable site visits to Urban Search and Rescue Teams cost approximately $30,000 each, and OEP has already let more than 100 MMRS contracts). The program will also make substantial demands of the time of OEP staff; the committee believes this task will necessitate at least one professional position.

SCENARIO-DRIVEN GROUP INTERACTION

Every site visit will involve not only individual interviews and observations but also two simultaneous 3-hour group meetings, each facilitated by two on-site evaluators, in which a group of 12 to 15 representatives from the community’s safety and health institutions will be required to answer questions about their community’s response to a fictional CBR terrorism incident. The models and scenarios are adaptations of three FEMA courses designed to help senior local government officials improve their abilities to respond to mass-casualty incidents involving the use of CBR weapons (Federal Emergency Management Agency, 2001c, d, e, f). Because of the overarching importance of interagency, intergovernmental, and public-private cooperation and coordination, the goal of this portion of the site visit is to give the community a chance to demonstrate the

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

existence of a well-understood process to coordinate all necessary capabilities to respond to a mass-casualty CBR terrorism incident, specifically, the ability to acquire, process, and appropriately distribute information required to effectively manage critical functions during an incident. The fact that the evaluators will conduct two parallel discussions will ensure that this ability is not confined to a single individual or a single individual in each institution.

Appendix F provides scenarios, discussion questions, and instructional material for the facilitators and evaluators (these roles should be assigned to different members of the site visit team). The scenarios involving chemical and radiological agents have been taken from the FEMA courses almost intact, but the FEMA scenario involving a biological agent, which involves an attack with anthrax, has been extensively modified to reflect both the knowledge about anthrax gained in the autumn of 2001 and the committee’s desire to include a scenario based on a truly covert release of a biological agent. The materials from the FEMA courses are designed to support either 3-day or 1-day courses, so considerable editing of discussion questions was necessary. Much of that was accomplished by focusing on coordination and cooperation (Do the participants know each other, and how they are supposed to interact?) rather than details of individual performance (Does the city have an adequate cache of equipment and supplies? Do the physicians in the community know how to handle a suspected smallpox case?), which will be assessed in other portions of the evaluation.

The participants should be selected by the leaders of the local MMRS. The committee recommends that OEP tell the local MMRS contact only that there will be two simultaneous scenario-driven group discussions and that OEP suggest that he or she should invite representatives of all the major agencies and institutions necessary for an effective response to a mass-casualty terrorism event. In most cases it will not be possible to have all the participating jurisdictions represented, but representatives of local agencies and institutions should not all be from the same jurisdiction. OEP should ask to review the list of invitees before the site visit and should take that opportunity to suggest additions that might be crucial to the discussion. Before the site visit OEP should also attempt to identify some potential critics of the local system, with or without the aid of the local MMRS leaders, and invite them to participate as well.

SUMMARY

The survey described in the previous chapter provides one tool for assessing the effectiveness of the MMRS program, namely, a survey soliciting the opinions of the communities themselves. This chapter comple-

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
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ments that approach by presenting the committee’s recommendations for an independent and systematic assessment of the response capabilities of the large metropolitan areas that have or will participate in the MMRS program.

Several important assumptions or principles underlie these recommendations:

  • Evaluation should be part of a continuous learning and continuous quality improvement program, not a one-time snapshot. This implies a continuing relationship between the communities and their evaluators that includes financial as well as technical and educational support.

  • “Preparedness” is a meaningless abstract concept without a specific threat; it should be seen as a process rather than a state.

  • Preparedness requires not only numerous specific capabilities, typically the responsibilities of independent offices, agencies, and institutions, but also seamless coordination of those capabilities into a coherent response. The former may be envisioned as the teeth of a comb, the latter as the base or backbone of the comb.

  • Information and the ability to acquire, process, and appropriately distribute it to essential sites and personnel are central to the effective management of critical incidents including terrorism in its many forms.

  • Evaluation is an exercise designed to guide distribution of local, state, and federal resources. Evaluations should be valued and understood as an opportunity for local communities to determine the areas in need of improvement and support rather than as a test of communities’ self-reliance.

  • A relatively small subset of the nearly 500 preparedness indicators identified in the Phase I report (Institute of Medicine, 2001) can be used to identify critical areas in need of improvement for a given community.

A set of 23 essential capabilities needed for an effective response to CBR terrorism was presented and used to guide the selection of a subset of preparedness indicators for use in a formal evaluation program. For each of those indicators, the committee then provided its opinion on what would constitute acceptable evidence of preparedness (preparedness criteria).

The chapter concludes with the committee’s recommendations on methods for gathering that evidence. Evaluations by OEP should be multilevel processes that include (1) periodic review of documents and records, (2) observation of community-initiated exercises and drills, and (3) an on-site assessment. The committee views the on-site assessment as constituting both interviews with individuals about specific capabilities and a scenario-driven group interaction focused on interagency and institutional cooperation and coordination.

Suggested Citation:"8 Feedback to Office of Emergency Preparedness on Program Success." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
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The Metropolitan Medical Response System (MMRS) program of the U. S. Department of Health and Human Services (DHHS) provides funds to major U. S. cities to help them develop plans for coping with the health and medical consequences of a terrorist attack with chemical, biological, or radiological (CBR) agents. DHHS asked the Institute of Medicine (IOM) to assist in assessing the effectiveness of the MMRS program by developing appropriate evaluation methods, tools, and processes to assess both its own management of the program and local preparedness in the cities that have participated in the program. This book provides the managers of the MMRS program and others concerned about local capabilities to cope with CBR terrorism with three evaluation tools and a three-part assessment method. The tools are a questionnaire survey eliciting feedback about the management of the MMRS program, a table of preparedness indicators for 23 essential response capabilities, and a set of three scenarios and related questions for group discussion. The assessment method described integrates document inspection, a site visit by a team of expert peer reviewers, and observations at community exercises and drills.

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