Preparing for Terrorism Tools for Evaluating the Metropolitan Medical Response System Program (2002) / Chapter Skim
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Appendix E Preparedness Indicators for Metropolitan Medical Response System Program Contract Deliverables
Appendix E Preparedness Indicators for Metropolitan Medical Response System Program Contract Deliverables
Pages 219-251
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E Preparedness Indicators for Metropolitan Medical Response System Program Contract Deliverables 219
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. P manning environment 2.04 Statement of the philosophy of approach 2.05 Description of the geographic area 2.06 and 2.07 Inclusion on steering committee of all relevant organizations, including broad base of organizations from emergency response disciplines -List of relevant safety and health organizations -Description of proposed mechanisms for coordination of responses -Designation of lead agency or official -List of relevant safety and health organizations -Plan for soliciting input or gathering data -Mission or vision statement -Map of metropolitan area or list of jurisdictions in metropolitan area -Representation by senior officials from public safety, public health, and health care communities -Organizational tables and contact numbers -Meeting -Draft do -Agreem.
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or other formal written agreement where appropriate -Evidence of ongoing analysis of community strengths, weaknesses, opportunities, and threats -Written commitment by participating jurisdictions and state officials -Designation of lead individual or official and contact information for each jurisdiction -Evidence of attendance and participation in steering committee meetings by representatives from public safety, public health, and health care communities (e.g., minutes) -Meeting minutes -Demonstration of effective coordination in an exercise or documentation of effective coordination in an actual incident with or without CBR agents -Ability of designated officials to talk knowledgeably about their agency's role in the MMRS plan -Identified strengths, barriers, and challenges -Priority list for planning efforts -List of designated officials and agencies and deadlines for each effort -Ability of representatives from different levels of key institutions to explain mission or vision statement to peer reviewer -Map or list of participating jurisdictions -See entry for proposed new plan element, Description of the planning environment -Written or oral guidance to drafters of the MMRS plan components -Restructured coordinating committee as required -File of periodic and after-action evaluations -Reports on quality and system improvements
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222 Deliverable 3: Primary MMRS Plan PREPARING FOR TERRORISM Plan Elements Inputs Processes 3.02 Indication of existing systems being enhanced 3.03 Establishment of interfaces with state plan 3.04 Coordination with other political, mutual-aid, or other MMRS program jurisdictions 3.05 Identification and plan for accommodating resident federal assets of potential use 3.07 Detailed notification and alert procedures 3.08 Detailed management procedures for public affairs -Relevant pre-MMRS disaster plans, emergency operations plans, hazmat procedures, and state and local laws and regulations -State plan -State plan POC -List of other relevant agencies in local jurisdictions, with POCs -List of resident or neighboring federal assets, with POCs 3.06 Identification of -Description of current command-and-control command-and-control measures measures -MMRS communication plans (telephone and fax numbers, e-mail addresses, radio frequencies and call signs, etc.) -Designated spokespersons and media plan -List of topics for preplanned media packages -List of news media outlets, including those serving non-English speakers and those with impaired sight or hearing -Protocols for media credentialing -Identific existing -Designa address -Meeting evidence -Sign-off POC -Meeting evidence -Sign-off -Meeting evidence local fec planning -Sign-off POCs oi MOUs, -Enhance commas MMRS ]
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of agreement that all affected agencies have agreed to integration into a command structure that in some instances will make them subordinate to a sister agency -Documented success in regular testing or actual use in an emergency -Draft or incomplete set of communiques -Collection of finished communiques for news media on agents, procedures, -Documented use of media packages in CBR and public safety agent-related hoaxes or incidents or other -Arrangements for backup communication hazmat or epidemic events systems through state emergency management agency or law enforcement channels
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-See Deliverable 10 3.14 Provisions for emergency -POCs for legal affairs -Confirm management of legal issues and -Clear explanation of legal status and liability of legal credentialing of medical and other personnel, including -Evidence volunteers, responding as part of the MMRS eliminat program -Copies of or reference to relevant laws and regulations -Procedure for requesting emergency waivers or exceptions
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-Documented resolution of any issues related to crossjurisdictional licensure and liability coverage -Periodic assessment of actual inventory -See Deliverable 10 -See Deliverable 10 -Confirmation of MMRS plan description -Confirmation by legal authorities that MMRS of legal issues by legal POCs plans conform to local, state, and federal -Evidence that efforts are under way to laws (e.g., the Emergency Medical Treatment eliminate legal obstacles to preparedness and Labor Act)
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From page 226... ...
226 Deliverable 3: Continued PREPARING FOR TERRORISM Plan Elements Inputs Processes 3.15 Provisions for emergency -MMRS plan management of patient tracking and record keeping 3.16 Provisions for augmentation of epidemiological services and support 3.17 Provisions for laboratory support 3.18 Provisions for crowd control 3.19 Provisions for protection of -Same as 3.18 treatment facilities and personnel -Evidence tracking health c area (e.g training -List of supporting agencies or institutions, with POCs -List of supporting agencies or institutions, with POCs -MMRS plan -List of available law enforcement and security assets, with POCs -Evidence to plane -Sign-off with MI, support -Evidence to plane -Sign-off with M} POCs -Evidence agreed designs: security private -Same as 3.20 A schedule for exercises -Inclusion on the schedule of an exercise of -Meeting all required MMRS program functions, exercise separately or together, at least on a yearly basis -Inclusion on the schedule of a full-scale field exercise at least every 2 years 3.21 Assignment of responsibility for -Namets) of designated individualist -Meeting after-action reports and addressing after-act report findings revision -Docume exercise reports, recomm
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~ rclse or Ins, yearly basis ,cale field -Demonstration of effective patient tracking in an exercise or a multiple-casualty incident of any sort involving large-scale movement of patients within and across health care facilities -Evidence of interaction with and input to planning by POCs -Sign-off or other evidence of agreement with MMRS plan by epidemiological support POCs -Evidence of interaction with and input to planning by POCs -Sign-off or other evidence of agreement with MMRS plan by laboratory support POCs -Evidence of formal or informal agreements with organizations -Demonstration of epidemiological support (data collection or analysis) in exercises, suspected CBR agent-related incidents, or natural disease outbreaks -Demonstration of laboratory support in exercises, CBR agent-related hoaxes, actual disaster, or CBR agent-related event -Demonstration of availability of anticipated assets on short notice for random check designated to provide emergency planned exercise, or actual emergency security personnel (e.g., National Guard, -Time from request to appearance on site if private security firms)
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POCs Deliverable 4: MMRS Plan for Forward Movement of Patients Using the National Disaster Medical System (NDMS) -Evidence mental ]
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E: PREPAREDNESS INDICATORS FOR MMRS 229 Processes Outputs Hers and oroner oonse Using -Evidence of interaction with local mental health organization or agency -Agreements with private organizations and individual practitioners to provide mental health services for all segments of population -Evidence of practitioner training or experience providing services to disaster victims and/or responders -Meeting minutes or other evidence of interaction with POCs in funeral business and religious community regarding mass fatalities -MOUs, contracts, or other evidence of support of MMRS plan by undertaking and religious POCs -After-action reports from other kinds of disasters or exercises that document coordination, availability, use, and effectiveness of mental health professionals -After-action reports from other disasters or crimes that document satisfactory processing of large numbers of human remains -Evidence of tabletop exercises testing disposition plans and procedures for fatalities Processes Outputs -Distribution of SOPs to emergency medical services (EMSs) , local hospitals :ient sating -Appointment or notification letter, instructions -Documentation of contact with NDMS -Identification of their own and federal POCs for facilities with signed NDMS agreements -Awareness of plan and SOPs by EMSs and hospital officials and when and how to initiate them -Sign-off by designated individualist -Evidence of NDMS support for MMRS plan and SOPs for activation (e.g., from joint training, tabletop demonstration of interface)
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5.02 Detailed procedures for detection and identification of agents 5.03 Detailed procedures for extraction of victims from incident site 5.04 Detailed procedures for administration of appropriate antidote 5.05 Detailed procedures for decontamination of victims 5.06 Procedures for victim triage and initial care before transport to definitive medical care facility -Detectors for all agents specified in the MMRS program contract -SOPs for use of detectors -National Fire Prevention Association (NFPA) standards for hazmat operations -SOPs reflecting state laws and local regulations and practices -NFPA standards on extraction of victims -SOPs reflecting state laws and local regulations and practices -Medical protocols for all agents specified in contract -SOPs reflecting state laws and local regulations and practices -List of any special equipment required -SOPs reflecting state laws and local regulations and practices -Percenta trained radiology -Number -1 rammp -Training -Percenta trained radiology -Number -1 rammp -Training -Percenta medical with ch' agents -Number ~ .
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og -Percentage of personnel trained -Hands-on demonstration (for peer reviewer or in a large-scale drill or actual hazmat incident) of knowledge of the protocol -Certification or other nationally recognized affirmation of CBR agent-specific knowledge and skills, if such means of verification become available in the future -Hands-on demonstration (for peer reviewer or in a large-scale drill or actual hazmat incident)
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-Purchase plan for appropriate antidotes and drugs -Written procedures for maintenance, disposition, deployment, and resupply 5.11 Procedures for procurement -List of equipment and supplies appropriate -Periodic and provision of appropriate for the designated agents, considering the that pert equipment and supplies (see needs of both adult and pediatric patients pharma~ Deliverable 10) -Purchase plan for appropriate equipment "use by' and supplies -Written procedures for maintenance, disposition, deployment, and resupply -List of suppliers with additional critical materials
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-Demonstration that appropriate types and quantities of antidotes and drugs are on hand or readily accessible -Demonstration of timely deployment of stocks in an exercise or actual event (see Deliverable 10) -Periodic inventory, including checks that perishable supplies and pharmaceuticals are within their "use by" dates (see Deliverable 10)
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234 PREPARING FOR TERRORISM Deliverable 6: Component Plan for Metropolitan Medical Strike Team (MMST) if Community MMRS Includes Such a Team Plan Elements Inputs Processes 6.01 MMST mission statement and concept of operations 6.02 Organization and membership of the team 6.03 Detailed procedures for activation and deployment 6.04 Detailed procedures for identification of agent 6.05 Detailed procedures for extraction of victims from the incident site 6.06 Detailed procedures for administration of appropriate antidote 6.07 Detailed procedures for human decontamination 6.08 Detailed provisions for triage and initial care of victims 6.09 Detailed preparation of victims for transport to definitive care facilities with sufficient supplies of appropriate antidotes to ensure adequate treatment -Text of plan, including mission and concept of operations -Mission statement and concept of operations -Organizational chart -Development and distribution of SOPs -See 5.02 -See 5.03 -See 5.04 -See 5.05 -See 5.06 -See 5.06 and 5.07 -Organiz' of name member -Regular -Periodic -See 5.02 -See 5.03 -See 5.04 -See 5.05 -See 5.06 -See 5.06
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E: PREPAREDNESS INDICATORS FOR MMRS me 235 Processes Outputs concept aerations ) Ps -Organizational chart and current list of names and contact information for membership of the team -Explanation of mission and concept of operations to peer reviewer by representatives of key MMRS program institutions -Description of organization and membership of the team to peer reviewer by selected sample of team members -Inclusion of all necessary areas of expertise on the team -Regular testing of activation procedures -Evidence of speed and completeness of -Periodic testing of deployment SOPs activation and deployment in exercises or actual incidents -See 5.02 -See 5.03 -See 5.04 -See 5.05 -See 5.06 -See 5.06 and 5.07 -See 5.02 -See 5.03 -See 5.04 -See 5.05 -See 5.06 -See 5.06 and 5.07
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From page 236... ...
-POCs for laboratory diagnosis system that includes field sampling, local laboratory screening, and public health laboratory network connection and capacity -List of trained personnel (and on-call schedules) to conduct epidemiological investigations and analyses to determine the scope and magnitude of the epidemic -Name, organization, and position of designated individual -MMRS plan or augmented preexisting plan -Stockpile or plans for acquisition and storage of appropriate vaccines, antibiotics, and antitoxins -List of potential sites for mass immunization or prophylaxis -List of personnel or sources of personnel to conduct mass immunization or prophylaxis -List of personnel or sources of personnel to distribute vaccines or antibiotics to sites of mass immunization or prophylaxis -System for recording persons who have received mass immunization or prophylaxis -Daily red data fro: - Establis .
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From page 237... ...
-Record or schedule of laboratory quality assurance training and testing -Evidence that the office monitoring indicators knows the name of designated individual and has multiple means of relaying relevant information -Percentage of response and caregiving personnel immunized if plan calls for prophylactic immunization of these individuals -MOUs or other evidence that sites and designated personnel are aware of and knowledgeable about their roles in the plan -See Deliverable 10 for preparedness indicators for supplies and equipment -Evidence of ongoing disease detection from actual cases, interviews by peer reviewers, or exercises or tests -Demonstration of effective surveillance for specific events (mass gatherings, controversial trials, etc.) -MMRS plan that addresses early recognition, mass immunization or prophylaxis, mass patient care, mass-fatality management, and environmental surety -Demonstration of appropriate use of earlywarning indicators in peer-review interview, exercise, or actual event -Percentage of laboratory personnel certified by 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 one of the designated agents -Confirmation by designated individual that he or she is the appropriate contact and demonstration that he or she is conversant with the MMRS plan -After-action report detailing successful response to a natural outbreak of disease (e.g., a meningitis or influenza vaccine campaign)
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7.09 New plans or augmentation of existing mass-fatality plans for respectful care and disposition of a large percentage of the population 7.10 Procedures for augmentation of existing morgue facilities and staff -MMRS plan that designates an individual (name, organization, and position) to make the decision to provide immunization or prophylaxis to staff and the community and the criteria to be used -Legal and regulatory references that provide the designated individual with the requisite authority Nomprehensive list of facilities, with POCs and telephone and fax numbers -Number of beds, isolation capacity, and infection control capacity in the community, including special centers for care -Mass-casualty plans of area hospitals -Medical protocols for at least the agents specified in the MMRS program contract (those responsible for anthrax, botulism, hemorrhagic fever, plague, smallpox, and tularemia)
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From page 239... ...
of interhospital equipment -Annual exercise of mass-casualty plans -Distribution of copies of medical protocols to all relevant sites -MOUs or other agreements with participating agencies, institutions, and organizations -Contingency contracts for use of nonmedical sites for casualty collection and expedient patient care -See 7.10 and 7.11 -Contingency contracts or other forward arrangements for obtaining storage capacity -Evidence of NDMS support for MMRS plan and SOPs for activation (joint training, tabletop demonstration of interface with DMORT) coordination of personnel, equipment, and supplies -Hands-on demonstration (in response to peer reviewer questions or in a drill or actual disease outbreak)
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From page 240... ...
240 Deliverable 7: Continued PREPARING FOR TERRORISM Plan Elements Inputs Processes 7.11 Procedures for decontamination or isolation of human remains when appropriate 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 7.14 Three levels of response: for incidents with up to 100 victims, 100 to 10,000 victims, and more than 10,000 victims IOM Alternative Three capacity levels: normal capacity, capacity with augmentation, and "overwhelmed" level -SOPs covering decision to decontaminate and the decontamination process -List of local, state, and federal environmental agencies, with POCs -Detection and agent identification equipment capable of verifying safety -Mass medical and infectious waste management plans -List of local, state, and federal environmental agencies, with POCs -Detection and agent identification equipment capable of verifying safety -Evaluation of each of the Deliverable 7 inputs described above relative to each of the three scenarios -Evidence morgue to distri and per -See 7.13 -Record plan by environs -Awaren. charged respons 1 .
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E: PREPAREDNESS INDICATORS FOR MMRS 241 Processes Outputs urinate onmental quipment onmental quipment e 7 inputs the three -Evidence that SOPs are available at morgue facilities in sufficient quantity to distribute to any expedient sites and personnel required -See 7.13 -Record of agreement with the MMRS plan by local, state, and federal environmental agencies -Awareness by the individual or agency charged with judging safety of responsibility and has SOP for decision making -Evaluation of each of the Deliverable 7 processes described above relative to each of the three scenarios -Hands-on demonstration of decontamination in an exercise or actual incident -See 7.13 -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 -Evaluation of each of the Deliverable 7 outputs described above relative to each of the three scenarios
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From page 242... ...
8.03 Provisions for the capability of local health care facilities to provide triage and initiate definitive care 8.04 Assurance of adequate security to support provision of emergency and definitive health care during and following a large-scale terrorism event -Comprehensive list of facilities, with POCs and telephone and fax numbers -Designated individual or office to initiate process, staff to carry it out -Communications equipment appropriate for rapid notice, e.g., radio, broadcast fax, or e-mail -Presence of plan at all local health care facilities -Availability of personal protective equipment required by plan -Capacities of facilities to secure all entrances and exits -Inventory of services and capabilities -Specification by each facility of three levels of capability: normal operations, operations with augmentation, and overwhelmed operations -SOPs on transfer process -MMRS plan -List of available law enforcement and security assets, with POCs -Periodic at least weeken. -Evidence are pros -Evidence and pro care of patients or drug-Evidenc~ .
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-Evidence that agreements include preexisting plans to allocate security staff when demand exceeds supply -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 -Time from initial contact until hospitals report beds and capabilities are available -Numbers of secondary infections of staff or other patients in prior 6 months -Current conversion rate for positivity for tuberculosis (purified protein derivative) skin tests among staff -Numbers of isolation rooms available, overall and in the ED -Numbers of tuberculosis, rubella, or varicella patients admitted to nonisolation rooms in prior 6 months -Numbers of staff furloughed due to exposure to patients with varicella, rubella, or other infectious diseases in prior 6 months -Numbers of hours from examination of most recent tuberculosis patient to isolation -Numbers, types, and durations of diversions in previous 3 months -Numbers and types of patients transferred out of the hospital to other facilities in previous 3 months -Expert assessment of MMRS program-wide hospital exercise or response to masscasualty event -Anticipated assets available on short notice for a random check, planned exercise, or actual emergency -Number of unauthorized entrants during a drill or exercise
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From page 244... ...
-Data on populations of communities participating in the MMRS program Communitywide list of physicians with hospital privileges, with telephone contact information -Medical treatment protocols for agents specified in MMRS program contract (nerve agents; blister agents; choking agents; blood agents; and those responsible for anthrax, botulism, hemorrhagic fever, plague, smallpox, and tularemia) in FY 2000 -Essential antidotes, antibiotics, and immune sera, in appropriate quantities -Medical protocols for at least 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)
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From page 245... ...
-Distribution of protocols to all physicians and availability of protocols at all major medical care sites -Training schedule -Numbers and percentages of staff trained on protocols -Evidence of effective collaboration in coping with recent national shortages of influenza and tetanus vaccines and gamma globulin and emergency shortages of antibiotics -Response times required to retrieve requested items in drills or in actual cases -Laboratory quality assurance test results -Demonstration of knowledge in responses to peer reviewer questions, exercise, or actual event -Certification or other nationally recognized affirmation of CBR agent-specific knowledge and skills, if such means for certification become available in the future -Number of hours from time of examination of tuberculosis patients to isolation -Number of isolation rooms available in ED and in total -Number of tuberculosis patients admitted to nonisolation rooms -Number of staff furloughed due to exposure to patients with varicella, rubella, or other infectious diseases -Demonstration of knowledge by EDs, intensive care units, and primary care physicians and nurses in responses to peer reviewer questions, exercise, or actual event -Certification or other nationally recognized affirmation of CBR agent-specific knowledge and skills, if such means for certification become available in the future -Compliance with existing protocols
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From page 246... ...
affects initial training requirements, continuing education, and refresher training needs -Telephone call list -Public communication plan -List of news media outlets and POCs -List of customary and alternative vendors of food, fuel, laundry, and other essential supplies -Numbers and locations of police and fire department personnel, emergency medical technicians, paramedics, vehicle drivers, ED staff (physicians and nurses) , hospital administration and infection control officers, chemical and radiation safety officers, local and regional public health authorities, and U.S.
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From page 247... ...
, with critiques provided to participants -Number of people (and percentage of the target workforce) trained -Number of communitywide exercises including disaster drills and tabletop exercises -Revision of training requirements reflecting previous training -Evidence from calls to random sample of list shows that the list is up to date -Percentage of staff returning in 2 hours -Evidence of no disruption of services due to shortages during a drill or masscasualty event -Response times for deliveries -Alternative supplier can deliver necessary supplies in 24 hours -Demonstration of knowledge of subject matter to peer reviewer by selected sample of trained personnel from all levels of all participating organizations or through functional drills, communitywide exercises, or responses to actual CBR agent, hazmat, or infectious disease outbreak events -Certification or other nationally recognized affirmation of CBR agentspecific knowledge and skills, if such means for certification become available in the future
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From page 248... ...
, . approprlare agencies -Hands-on as well as didactic training schedule -List of CBR agents addressed Deliverable 10: MMRS Plan for Pharmaceuticals and Equipment -Number provide courses critique' -Number the tags Plan Elements Inputs Processes 10.01 List of pharmaceuticals consistent with mission of MMRS program 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 10.03 Timetable for procurement of pharmaceuticals and equipment -List of desired pharmaceuticals -MMRS program mission statement -Medical treatment protocols for agents specified in MMRS program contract (nerve agents; blister agents; choking agents; blood agents; and those responsible for anthrax, botulism, hemorrhagic fever, plague, smallpox, and tularemia)
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From page 249... ...
by a pharmacy and therapeutics committee -Algorithm for calculating required quantities of pharmaceuticals -Verification that a project manager can explain the derivation of the algorithm to the satisfaction of an expert peer reviewer -Establishment of mechanisms for review and update of pharmacopoeia -Establishment of mechanisms for monitoring pharmaceutical expiration dates and replacing stock -List that includes all treatments and vaccines specified in MMRS program medical treatment protocols -Availability of all essential antidotes, antibiotics, and immune sera, in appropriate quantities, for inspection by site-visit team or peer reviewer -Availability of all essential antidotes, antibiotics, and immune sera, in appropriate quantities, for inspection by site-visit team or peer reviewer
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From page 250... ...
10.05 Identification of a property officer responsible for all property received and purchased under MMRS program contract 10.06 Harmonization of equipment purchases with equipment received from DOD, DOT, and the Federal Emergency Management Agency 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) -Name and contact information for designated property officer -List of essential detection, protective, and decontamination equipment for use both in the field and in hospitals -List of protective, detection, and decontamination equipment previously received from other federal sources -List of authorized local recipients -SOPs for release of pharmaceuticals and equipment -SOPs, including phone and e-mail contacts at the Centers for Disease Control and Prevention (CDC)
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From page 251... ...
E: PREPAREDNESS INDICATORS FOR MMRS 251 Processes Outputs rage ntenance Lesignated i, and both in usly and ontacts nd wn and health by federal, tensing of -Periodic assessment of safety of storage and delivery systems -Periodic testing of appropriateness of drugs supplies (outdated supplies, currency of pharmacopoeia) by a pharmacy and therapeutics committee -Periodic drills, actual events, or questioning by expert peer reviewer demonstrate mechanisms for coordination of activity at multiple sites as well as return and decontamination of equipment and unused supplies -Records of periodic maintenance of equipment -Records of training of logistics personnel on maintenance procedures -Records of purchase and current location of all property -Purchase plan that reflects equipment and supplies on hand from other sources -Periodic training and testing of distribution plan -Periodic training and testing of distribution plan -Evidence that the mechanism of delivery and storage is secure in natural disasters, mock drills, earthquakes, or hazmat events -Consistency of inventory with records of pharmacy and therapeutics committee meetings -Knowledge of procedures for return of unused supplies and decontamination of equipment by logistics personnel -Evidence that a sample of equipment selected by peer reviewer is in working order -Performance of required maintenance and/or prompt retrieval of maintenance manual by logistics personnel when queried by peer reviewer -Retrieval of inventory and maintenance records by property officer -Evidence that a sample of property in acceptable condition can be produced for expert peer reviewer at locations specified in property officer records -Evidence that sum of equipment on hand, on order, or scheduled for purchase is not greater than documented need -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 will be rapid enough to maintain local supplies after the initial 24 hours of an event
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