4
Metropolitan Medical Response System Program Contracts

Any evaluation of the effectiveness of the Metropolitan Medical Response System (MMRS) program must involve examination not only of the capabilities of the participating cities but also the program’s requirements. More simply, one needs to know not only how well the cities carried out the terms of their agreement with the U.S. Department of Health and Human Service’s Office of Emergency Preparedness (OEP) but also whether those terms could reasonably be expected to result in enhanced capabilities for MMRS program cities. This chapter therefore describes those terms in some detail.

First, unlike many federal programs of assistance to state and local governments that provide funds by means of grants or cooperative agreements, OEP chose to use contracts as the mechanism for providing funds to participating MMRS program cities. The distinguishing characteristic of contracts is the level of detail provided in the “statement of work.” Unlike grants, which often support desired processes and activities without specifying the expected product in any detail, contracts focus more closely on the products (“deliverables” in government jargon) and less closely on how the contractor is to produce them. This chapter examines the products that the MMRS program contracts require the cities to provide and touches briefly on the means by which OEP evaluates those products for compliance with the contract terms. Subsequent chapters focus on how to tell whether such compliance has resulted in a truly enhanced capability to respond to chemical, biological, and radiological (CBR) terrorism.

A second important and distinctive feature of the MMRS program is



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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program 4 Metropolitan Medical Response System Program Contracts Any evaluation of the effectiveness of the Metropolitan Medical Response System (MMRS) program must involve examination not only of the capabilities of the participating cities but also the program’s requirements. More simply, one needs to know not only how well the cities carried out the terms of their agreement with the U.S. Department of Health and Human Service’s Office of Emergency Preparedness (OEP) but also whether those terms could reasonably be expected to result in enhanced capabilities for MMRS program cities. This chapter therefore describes those terms in some detail. First, unlike many federal programs of assistance to state and local governments that provide funds by means of grants or cooperative agreements, OEP chose to use contracts as the mechanism for providing funds to participating MMRS program cities. The distinguishing characteristic of contracts is the level of detail provided in the “statement of work.” Unlike grants, which often support desired processes and activities without specifying the expected product in any detail, contracts focus more closely on the products (“deliverables” in government jargon) and less closely on how the contractor is to produce them. This chapter examines the products that the MMRS program contracts require the cities to provide and touches briefly on the means by which OEP evaluates those products for compliance with the contract terms. Subsequent chapters focus on how to tell whether such compliance has resulted in a truly enhanced capability to respond to chemical, biological, and radiological (CBR) terrorism. A second important and distinctive feature of the MMRS program is

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program that the contracts bypass the state governments. Although cities are encouraged to involve surrounding jurisdictions and ensure that their plans are compatible with existing state emergency and disaster management plans, OEP has followed the lead of the U.S. Department of Defense (DOD), which was designated the lead federal agency by the Defense Against Weapons of Mass Destruction Act of 1996 (P.L. 104-201). The act, among other provisions, required DOD to provide civilian personnel of federal, state, and local agencies with training and advice on emergency responses to the use or threatened use of weapons of mass destruction (WMD). DOD decided to carry out that charge by providing training to the 120 cities with the largest core populations, which equates to all U.S. cities with populations greater than 144,000 in the 1990 census. The populations of those 120 cities represent about 22 percent of the U.S. population and are located in 38 states and the District of Columbia. OEP logically sought to leverage its MMRS program efforts by focusing on the jurisdictions slated to receive DOD training. See Appendix C for a list of the MMRS program cities by the first fiscal year of their contract with OEP. FUNCTIONAL AREAS COVERED The basic strategy of the MMRS program is to enhance local capabilities by organizing, equipping, and training local fire, rescue, medical, and other emergency management personnel to deal with the consequences of a terrorist attack with CBR agents. These personnel, usually a subset of emergency personnel that is tailored to each city, receive training on military chemical and biological agents; specialized protective, detection, diagnostic, decontamination, communications, and medical equipment; antidotes, antibiotics, and other pharmaceuticals and medical supplies; and enhanced emergency medical transport and emergency department capabilities. The program seeks to enhance capabilities in other areas as well, including threat assessment, public affairs, epidemiological investigation, expedient hazard reduction, mass-casualty care, mental health support, victim identification, and mortuary services. Perhaps the most important component of the program is the planning and organization that is required to identify and involve all the local, state, and federal offices and agencies with relevant resources, responsibilities, knowledge, and skills. Despite some changes in the wording of the contracts and the number and nature of the deliverables since 1997, the core content of the MMRS program contracts covers the following activities: detection and identification of the toxic agent or disease, extraction of victims from contaminated areas,

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program decontamination of exposed persons (chemical or radiological incidents) and control of infection (biological incidents), emergency treatment of victims, triage and patient transport to definitive care, definitive care, mass immunization or prophylaxis, mass fatality management, and environmental surety (identifying residual health risk). PRODUCTS DEMANDED As noted earlier in the report, the original concept of a stand-alone Metropolitan Medical Strike Team (MMST), focused in large measure on augmenting existing hazardous material (hazmat) and emergency medical services in the event of an obvious multivictim attack involving a chemical weapon, has evolved into support for a wider-ranging system for responding to a variety of terrorism incidents. As a result, the products demanded of the contracting cities have changed since the program began in 1997. For example, all 1997 contracts were later amended (and additional funding was provided) to require a much more detailed plan for addressing biological terrorism incidents. Contractors were asked to plan responses for incidents of three different magnitudes: those with up to 100 victims, those with more than 100 but less than 10,000 victims, and those with more than 10,000 victims. Extensive guidance was provided in the statement of work, and 6 new deliverables were specified, in addition to the 10 required by the initial 12-month agreement. The contracts awarded in fiscal years 1999, 2000, and 2001 are very similar to one another, although they differ in a number of respects from the fiscal year 1997 contracts (no new MMRS program contracts were awarded in fiscal year 1998). The 1997 cities’ “bioterrorism supplement” was incorporated into the body of the contract in subsequent years, albeit with far less detail in the statement of work. Another change allows cities to build the capabilities of an MMST into their existing response organizations rather than create a stand-alone team. Smaller changes clarified OEP’s intent in a number of places and provided cities with additional information about acceptable actions in others. No substantive requirements were added or deleted, and so, in the interests of brevity, only the provisions of the fiscal year 2000 MMRS program contract are presented here. MMRS Program 2000 Contracts Contracts awarded to the fiscal year 2000 MMRS program cities are

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program 18 months in duration and call for the phased delivery of 12 products. The contracts also provide for an extension (Option 1) of 12 additional months to acquire the pharmaceuticals and equipment approved in the basic plan and any other actions necessary to make the MMRS operational. Exercising the option entails submission of monthly progress reports, a list of acquisitions, and a final addendum to the MMRS plan verifying demonstrated operational capability. The deliverables are numbered and printed in boldface, followed by the associated text from the contract statement of work. The comments of the Institute of Medicine Committee on Evaluation of the Metropolitan Medical Response Program are enclosed in brackets. Meeting with Project Officer (within 2 weeks of contract award). Discuss the purpose of this contract and review key aspects of the accepted proposal. The MMRS Development Plan (within 3 months of contract award) [the plan for developing a plan]. Outline the approach [who, what, when, how] to the creation of an enhanced ability to deal with a terrorist use of a weapon of mass destruction (WMD), and to identify how the public safety, public health, and health services sector responses to a terrorist incident will be coordinated. This MMRS Development Plan should detail the proposed leadership and membership of the development team and the philosophy underlying the proposed approach, along with a description of the geographic area that the plan will cover. The plan must also include a roster of the Steering Committee membership, representing the relevant organizations that will assist in the planning and development of the MMRS. Consideration should be given to the following Steering Committee membership: EMS [emergency medical services], EMS Project Medical Directors, public and private hospital representation, hospital ED [emergency department] representation from major receiving hospitals, local and state emergency management, Local Emergency Planning Committees, National Guard, local and state public health departments (infectious disease representation), mental health, the 911 system, poison control centers, Medical Examiner, local lab representation, police/FBI [Federal Bureau of Investigation] (including bomb squad), American Red Cross, and local federal agency representatives (i.e., DOD, VA, DOE, EPA, FEMA [U.S. Department of Defense, U.S. Department of Veterans Affairs, U.S. Department of Energy, the Environmental Protection Agency, and the Federal Emergency Management Agency]) where available. Primary MMRS Plan (within 6 months of contract award). Develop a Primary Metropolitan Medical Response System (MMRS) Plan for managing the human health consequences of a terrorist incident

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program involving the use of weapons of mass destruction (WMD), i.e., a nuclear, radiological, biological and/or chemical device capable of creating mass casualties. The MMRS is considered to be an enhanced local capability for an existing system. The MMRS plan must interface with the state plan, and should be coordinated with other appropriate political jurisdictions (e.g., county government), with nearby/neighboring emergency response systems, and with nearby/neighboring MMRS systems (within approximately 25 miles of those with which mutual aid is anticipated to be used). This plan should identify and accommodate resident federal/state assets that may be useful for the city/metropolitan area response plan. The MMRS should develop plans: for command and control, for notification and alert procedures, for management of public affairs, for provision of accurate and timely information, for centralized communication control, for control of transportation assets, for management/augmentation of medical personnel, for management of medical supplies and equipment, for emergency management of legal issues and credentialing, for emergency management of patient tracking/record keeping, for augmentation of epidemiological services and support, for laboratory support, for crowd control, protection of treatment facilities and personnel, for establishing a schedule for exercises, and for assigning responsibility for afteraction reports and addressing report findings. Mental health services should be designed for the care of emergency workers, victims and their families as well as others in the community who need special assistance in coping with the consequences of this type of event. Plans for the proper examination, care and disposition of any humans who do not survive the attack should be included. Component MMRS Plan for forward movement of patients utilizing the NDMS [National Disaster Medical System] (within 8 months of contract award). To the extent that local resources are insufficient to provide the definitive health care required for all of those directly affected by the attack, develop a component of the MMRS Plan for forward movement of patients to other areas of the region or nation. An important consideration here is: who will make the decision to implement the forward movement of patients? This transportation and care would be provided by the National Disaster Medical System (this plan should be developed in coordination with the applicable Federal Coordinating Hospital). Component MMRS Plan for responding to a chemical, radiological, nuclear, or explosive WMD event [NOT biological] (within 9 months of contract award). Develop a component of the MMRS Plan for responding to and managing the health consequences of an incident resulting from the use of a chemical, radiological, nuclear, and explosive WMD. The MMRS should

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program be able to detect and identify the weapon material or agent, extract the victims, administer the appropriate antidote, decontaminate victims, triage them and provide primary care prior to their transportation to a definitive medical care facility. The MMRS shall include plans for emergency medical transportation of the patients as well as emergency and inpatient services in hospitals that have the capacity and capability to provide the definitive medical care required, or to pre-designated off-site treatment facilities. Management of patients arriving at hospitals without prior field treatment/screening or decontamination should also be part of the MMRS. This plan shall also include procurement and provision of appropriate pharmaceuticals (sufficient to provide care for up to 1,000 victims), equipment, and supplies consistent with the mission and the MMRS. No pharmaceuticals or antidotes may be purchased until the list has been submitted to, and approved by, the Project Officer. Component plan for MMST if it is a component of your MMRS (within 12 months of contract award). If a clearly identifiable Metropolitan Medical Strike Team (MMST) is a component of your MMRS Plan, develop a component of the MMRS Plan for MMST capability that includes its mission statement, organization, membership, and concept of operations. Included in this operational plan shall be provisions for its activation, deployment, CBR agent identification, extraction of victims from the incident site, antidote administration, human decontamination, triage and primary care, and preparation of victims for transportation to definitive care facilities with sufficient supplies of appropriate antidotes to assure adequate treatment. Component plan for managing the health consequences of a biological WMD (within 18 months of contract award). Develop a component of the MMRS Plan to manage the health consequences of the release of a biological weapon of mass destruction. This plan should be integrated with existing or planned local and state health surveillance plans for bioterrorism and influenza pandemic planning. This portion of the plan should address five general areas. Early Recognition: The contractor should identify, describe, or develop early warning indicator(s) which will be used to alert local officials of a biological terrorist event, ensuring timely notification and activation of response plans. This plan should identify who will receive notification, and who will make the decision to further implement response plans. Mass Immunization/Prophylaxis: In this section, the contractor should highlight, develop, or augment existing plans for managing and implementing mass immunization/prophylaxis. In developing this plan, it should be assumed that the Federal government would assure the availability of vaccines and antibiotics within 24 hours of notification. Key components of this plan include a description of the decision making pro-

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program cess to initiate a mass immunization campaign, together with plans for identifying the affected population. Mass Patient Care: In this section, the contractor should develop or augment existing plans for providing care for a significant portion of the population. Key components of this plan include plans for rapid expansion of existing healthcare system capacity, and plans for taking care of people in excess of either existing or expanded capacity. Mass Fatality Management: In this section, the contractor should develop or augment existing plans for providing respectful care and disposition for a large percentage of the population. Key components of this plan are plans for augmenting existing morgue facilities and staff, and plans for decontamination/isolation procedures where appropriate. Environmental Surety: In this section, the contractor should describe or develop a plan for identifying environmental risk, need for decontamination or vector intervention, and a process for safe re-entry into a suspect area in consultation with local, state, and federal environmental agencies. The size and robustness of any response to the use of a biological WMD will be determined by the specific biological agent. As a result, response planning should be considered at three (3) levels: Incidents with up to one hundred (100) victims, Incidents with one hundred (100) to ten thousand (10,000) victims, Incidents with more than ten thousand (10,000) victims. A detailed list of biological response planning considerations is included as an attachment. (This list is meant for your use as a planning tool only; it is not meant to be prescriptive in any way). A list of biological agents that should be considered is included as an appendix. [Those responsible for smallpox, anthrax, plague, botulism, tularemia, and hemorrhagic fever. The agent responsible for brucellosis was included in 1997 contracts, but those responsible for botulism and hemorrhagic fever were not.] Component plan for local hospital healthcare system (within 18 months of contract award). Develop a component of the MMRS Plan for the local hospital and healthcare system. Current JCAHO [Joint Commission on Accreditation of Healthcare Organizations] standards for emergency preparedness address an emergency preparedness management plan (EC.1.6), a security management plan (EC.1.4), hazardous materials and waste management plan (EC.1.5), and emergency preparedness drills (EC.2.9). Ensure that this portion of the plan addresses the following eight general areas.

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program Plans for notification of hospitals, clinics, HMOs [health maintenance organizations], etc., that an incident has occurred. Plans and procedures in place for hospitals, clinics, and HMOs to protect them from contamination from environmental or patient sources. Plans for providing triage and initiation of definitive care at local healthcare facilities. Plans for adequate security to support these activities. Availability of adequate personal protective equipment for hospital and clinic providers. Adequate pharmaceuticals and equipment (ventilators) are available locally, or that plans are in place to obtain them in a timely manner. Ability of medical staff to recognize and treat casualties caused by WMD agents. Treatment protocols are readily available. MMRS Training Plan including training requirements and a follow-on Training Plan (within 18 months of contract award). Develop a Training Plan for the MMRS that identifies training requirements for MMRS personnel, including all first responders, EMTs [emergency medical technicians], paramedics, vehicle drivers, emergency department and other hospital personnel who will be providing care to victims of a WMD incident. In the event that the DOD Domestic Preparedness training has been provided to the city, the contractor should indicate how the training received, including FEMA/DOJ training, will be integrated into meeting the initial training requirements as well as continuing education and other refresher training needs. For the training of hospital personnel, it is important to note that Presidential Decision Directive 62 (PDD 62) highlights the VA’s role in the training of medical personnel in NDMS hospitals. MMRS pharmaceutical and equipment plan that includes a maintenance plan and a procurement timetable for equipment and pharmaceuticals approved by the Project Officer (within 18 months of contract award). Submit a list of pharmaceuticals consistent with the mission of the MMRS. Pharmaceuticals should be sufficient to provide care for at least 1,000 victims for a chemical incident, and for the affected population for the first 24 hours of response for a biological incident (it should be assumed that the Federal government would assure the availability of vaccines and antibiotics within 24 hours of notification). Equipment may include personal protective equipment, detection equipment and decontamination equipment (both field and hospital). A timetable for procurement of the above items and a plan for equipment maintenance and pharmaceutical storage should accompany this. A property officer responsible for all property received and purchased under this contract shall be iden-

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program tified. Equipment purchases under this contract must be harmonized with equipment received from DOD, DOJ, and FEMA programs. Only equipment and pharmaceuticals approved by the Project Officer shall be purchased under this contract. Monthly progress reports and a final report 18 months after contract award. These reports should describe successful endeavors and barriers encountered. Any barrier encountered should be accompanied with a plan to resolve the issue. Include all meeting minutes that relate to MMRS development. Option 1 deliverables [if the city’s MMRS is not operational upon submission of the final report] are: a detailed list of equipment and pharmaceuticals acquisitions, continued monthly progress reports, and a final addendum to the primary MMRS plan certifying that the MMRS is operational. Carry out remaining actions that are required to assure that the MMRS is operational, including acquisition of pharmaceuticals and equipment as identified, planned and approved in deliverable #10. Continue to submit brief monthly progress reports and a final report at the end of the contract period. The final report must constitute an assessment of response capabilities (enhanced or created) that exist now as a result of the MMRS planning effort. The report shall identify actual equipment and pharmaceuticals procured and received under the contract. Identify additional assets/requirements that you will look to the Federal government to provide. These additional assets must be addressed in an addendum to the Primary MMRS Plan. The final report must include a statement that the MMRS has demonstrated operational capability. The final report shall be presented to the Project Officer no later than 12 months from the effective date of the option period. CONTRACT DELIVERABLE EVALUATION INSTRUMENT OEP staff uses the Contract Deliverable Evaluation Instrument to determine whether the contractor has met the terms of the contract, that is, has provided all the required deliverables and addressed all the elements of those deliverables specified in the contract. The contractor is encouraged to use the same instrument as a guide to action throughout the contract. Appendix D provides a copy of the checklist for the cities whose contracts began in fiscal year 2000. It served as the starting point and framework for the committee’s analysis of potential preparedness indicators that is described in Chapter 6 and Appendix E.