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8 Feedback to Office of Emergency Preparedness on Program Success
Pages 113-163

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From page 113...
... 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.
From page 114...
... 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.
From page 115...
... 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.
From page 116...
... Equipment and supplies -purchase and maintenance (general purpose as well as specialized for CBR agents) -reception and distribution of "push package" from CDC 6.
From page 117...
... 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.
From page 118...
... 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
From page 119...
... Pr aredness Indicator ep Documentation of effective coordination in an exercise or an actual incident with or without CBR agents. · The lead agency provides written documentation of an MMRSwide response system that includes management, operations, logistics, planning and intelligence, and finance and administration activities.
From page 120...
... terrorism incident by public safety, public health, exercise ~ and health services sectors will be coordinated CBR ages 3.04 Coordination with other political, mutual-aid, Evidence or other MMRS program jurisdictions demonstr local plan 2 Communication system 3.07 Detailed notification and alert procedures · Docun development via redundant systems during · System service · Mutua comma comma 3.09 Provisions for accurate and timely dissemination of information among MMRS members Demonsb periods 0 tests or u 8.01 Procedures for notification of hospitals, clinics, · Percen health maintenance organizations (HMOs) , etc., that during an incident has occurred · Time fir hospital system 8.New 1 Procedures for recall of staff · Calls tc that lisl · Percenl 3.
From page 121...
... Mutual aid agreements with surrounding communities insure interoperability of key communication systems . X X X Demonstration of effective use of all systems in X periods of peak demand through unannounced tests or use in an actual emergency · Percentage of facilities contacted in 1 hour during weekly notification checks · Time from initial contact to initiation of hospital disaster plan or incident command system · Calls to random sample of list demonstrate that list is up to date · Percentage of staff returning calls in 2 hours A communitywide assessment identifies strengths, barriers and challenges, and a priority list for planning efforts Collection of after-action reports .
From page 122...
... First responder protection 5.11 Procedures for procurement and provision of Demons appropriate equipment and supplies quantities purchaser 8.05 Availability of adequate personal protective equipment for hospital and clinic providers Demons by a respi
From page 123...
... · Collection of finished communiques · Documented use of media packages in CBR agent- X related hoaxes or incidents or other hazmat-related or epidemic events Demonstration that the appropriate types and quantities of equipment and supplies have been purchased and are readily accessible Demonstration of competency with equipment (e.g., by a respirator fit test) for expert peer reviewer X X X X X X X X X X
From page 124...
... Diagnosis and agent identification 11. Decontamination 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 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 CUR agents 5.05 Detailed procedures for decontamination of victims 5.09 Procedures for management of patients arriving at hospitals without prior field screening or decontamination Hands-o: large-sea and effic: contamir Hands-o: large-sea administ Hands-o~ a large-sc triage ant · Numb peeve · Numbs hospitc Hands-or large-scal detection · Demor indicat actual ~ Percen.
From page 125...
... of victim triage and initial care · Numbers, types, and durations of diversions in previous 3 months X · Numbers and types of patients transferred out of the X hospital to other facilities in previous 3 months Hands-on demonstration (for peer reviewer or in a large-scale drill or actual hazmat incident) of agent detection and identification · Demonstration of appropriate use of early-warning indicators in peer-review interview, exercise, or actual event Percentage of laboratory personnel certified by X relevant professional organization 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 · Laboratory quality assurance test results X · Demonstration of knowledge in responses to peer reviewer questions, exercise, or actual event · Hands-on demonstration (for peer reviewer or in a large-scale drill or actual hazmat incident)
From page 126...
... Distribution of supplies, equipment, and pharmaceuticals Numb other · Current (purifi - Numb availal (EDs) · Numb patient 6 mont Numbs patient disease For the from e 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 lO.New 1 Procedures for distributing pharmaceuticals and equipment to local personnel and facilities lO.New 2 Procedures for requesting, receiving, and distributing pharmaceuticals from the National Pharmaceutical Stockpile (NPS)
From page 127...
... skin tests among staff Numbers of negative-pressure isolation rooms available, overall and in emergency departments (EDs) Numbers of tuberculosis, rubella, or varicella X patients admitted to nonisolation rooms in prior 6 months Numbers of staff furloughed due to exposure to X patients with varicella, rubella, or other infectious diseases in prior 6 months X X · For the most recent tuberculosis patient, the time X from examination to the time of isolation Availability of anticipated assets on short notice for X random check, planned exercise, or actual emergency Availability and response times in exercises or actual X mass-casualty events · Awareness of plan and procedures and when and how to initiate them by emergency medical services and hospital officials · Evidence of NDMS support for MMRS program X plan and procedures for activation 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 Evidence from drill, actual event, or questioning by expert peer reviewer that local distribution of NPS supplies (push packages and vender-managed inventory)
From page 128...
... Definitive medical care 3.12 Detailed procedures for the management and Demonst~ augmentation of medical personnel systems, medical through ~ emergent 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 · Docurr crossing · Percen weekly · Time fir disaste · Availal and im .
From page 129...
... treat Demonstration that a lead agency responsible for X 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) Demonstration that the lead agency's disaster plan X reflects special standard operating procedures for sheltering evacuees of CBR agent-related incidents Demonstration of effective use of all communication X 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.)
From page 130...
... 1.8 Crowd and traffic control 3.18 Provisions for crowd control · Demor for cro' disturb · Demon for thee · Demon is avail 3.19 Provisions for protection of treatment facilities After-acti and personnel control at sporting ~ and/or in 19 Evacuation and quarantine Not addressed in contracts · Writter decisions, operations upon a: as shell of India of patio · Demon verbal) a conta · Demon verbal)
From page 131...
... . Demonstration that an established plan provides X for crowd control at special events or during civil disturbances Demonstration that officers receive regular training X for these responsibilities - Demonstration that adequate protective equipment X is available for police officers After-action reports that document crowd and traffic X control at events with large attendances such as sporting events, concerts, and political conventions and/or in prior natural or technological disasters · Written plan that includes procedures for deciding X 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.
From page 132...
... Process for continuous evaluation of needs and resources . 7.11 Procedures for decontamination or isolation of human remains 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 Not addressed in contract 3.21 Assignment of responsibility for after-action reports and addressing report findings Demonsb reviewer; performs disease or Same as c Demons practical ~ human hi victims, a: are availa Possess institut During prolong hazmat Eviden respon.
From page 133...
... Hands-on demonstration of decontamination in an exercise or actual incident 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 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 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 · Possession by all participating agencies and institutions of a collection of after-action reports · During-action reports from extended exercises or prolonged responses to actual CBR agent or hazmat events · Evidence for changes in structure or functioning in X response to deficiencies identified in after-action or during-action reports X X X X X
From page 134...
... · 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.
From page 135...
... 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.
From page 136...
... 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)
From page 137...
... 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.
From page 138...
... · The lead agency can document that at least 80 percent of designated personnel have been immunized.
From page 139...
... · 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.
From page 140...
... 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)
From page 141...
... 10. Diagnosis and Agent Identification Preparedness Indicator Hands-on demonstration (for peer reviewer or in a large-scale drill or actual hazmat incident)
From page 142...
... 11. Decontamination of Victims Pr aredness Indicator ep Hands-on demonstration (for peer reviewer or in a large-scale drill or actual hazmat incident)
From page 143...
... · 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.
From page 144...
... · 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.
From page 145...
... · EMS and hospital systems understand the predetermined protocol in the plan for the distribution of pharmaceuticals, supplies, and equipment, including: o the quantity and type of supplies and equipment available, o the locations of the primary and secondary storage sites, o the need for 24-hour accessibility to all storage sites, 0 the priorities for distribution, o 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)
From page 146...
... 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)
From page 147...
... . Pr aredness Indicator ep The lead agency's disaster plan reflects special operating procedures for sheltering evacuees in scenarios involving CBR agents.
From page 148...
... 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 per· A log confirms that 80 percent of facilities were notified within 1 Pr aredness Indicator ep Time from initial notification to initiation of hospital disaster plan or incident command system.
From page 149...
... · 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.
From page 150...
... 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: o 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)
From page 151...
... · 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.
From page 152...
... · The plan provides for the handling of mass casualties. · The plan includes a security plan for potential treatment facilities and their personnel, including: 0 controlled access to the facility, 0 controlled access to the grounds, 0 traffic control measures, and 0 a clear definition of hospital security and police roles and responsibilities.
From page 153...
... · 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.
From page 154...
... 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.
From page 155...
... Pr aredness Indicator ep 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.
From page 156...
... · 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 0 demonstrate the use of detection and agent identification equip0 demonstrate the use of personal protective equipment, and 0 demonstrate use of a field management system for incorporation of specialty environmental resource agencies into the MMRS plan.
From page 157...
... · 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.
From page 158...
... · 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.
From page 159...
... 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.
From page 160...
... 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.
From page 161...
... 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)
From page 162...
... 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.
From page 163...
... 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.


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