Much of the initial burden and responsibility for providing an effective response, by medical and public health professionals, to a WMD terrorist attack rests with the local governments, with support from State and Federal agencies. In a chemical incident, public safety agencies will lead the response and be supported by the public health and health services sectors. The initial chemical response will seek to

• detect and identify the unknown agent;
• extract victims from the contaminated area;
• administer appropriate antidotes to those exposed;
• decontaminate those in the contaminated area;
• triage victims;
• provide primary care; and
• transport patients to definitive care facilities.

A biological scenario will challenge communities in a very different manner. While the chemical scenario displayed the characteristics of a traditional hazardous materials response, the covert release of a biological agent would focus extensively on the public health and health services communities. Communities must have means for early recognition of a biological terrorist event. Jurisdictions will have to identify, describe, or develop "early warning indicator(s) which will be used to alert local officials, ensuring timely notification and activation of response plans

In both situations, chemical or biological, local health officials, with assistance from Federal and State governments, will be called on to provide protective and responsive measures including:

• Mass patient care, including the establishment of auxiliary, temporary treatment facilities and/or procedures for the movement of overflow patients to other geographic areas for care, usually through the National Disaster Medical System (NDMS).
• Mass immunization or prophylactic drug treatment for groups known to have been exposed to a WMD terrorist event, for groups who may have been exposed, and for populations not already exposed but at risk of exposure from secondary transmission or from the environment.
• Mass fatality management to provide respectful and safe disposition of the deceased.
• Cleanup of the environment.

The Defense Against Weapons of Mass Destruction Act of 1996 directs the Secretary of Defense to take immediate actions to both enhance the capability of the federal government to respond to terrorist incidents and to support improvements in the capabilities of state and local emergency response agencies. In recognition of this requirement, an amendment (widely known as Nunn–Lugar II or Nunn–Lugar–Domenici after its congressional sponsors) to the Defense Authorization Act for Fiscal Year 1997 (P.L. 104-201) authorized $100 million to establish a military rapid response unit; to implement programs providing advice, training, and loan of equipment to state and local emergency response agencies; and to provide assistance to major cities in establishing "medical strike teams."

It is these strike teams, which are now the responsibility of the Department of Health and Human Services (HHS), specifically the Office of Emergency Preparedness (OEP) that are the subject of the proposed project. OEP now has contracts with 72 jurisdictions to develop Metropolitan Medical Response Systems (MMRS) by organizing, equipping, and training groups of local fire, rescue, medical, and other emergency management personnel. The goal of these teams is to enhance local planning and response systems capability, tailored to each city, to care for victims of a terrorist incident involving a weapon of mass destruction (nuclear, chemical, or biological) This is accomplished by providing special training to a subset of local emergency personnel (120 to 300, depending on the size of the metropolitan area); specialized protective, detection, decontamination, communication, and medical equipment; special pharmaceuticals and other supplies; and enhanced emergency medical transport and emergency room capabilities. Other capabilities include threat assessment, public affairs, epidemiological investigation, expedient hazard reduction, mental health support, victim identification, and mortuary services.

To develop and enhance MMRS systems, we must better understand and evaluate their "success". There is an ongoing need to systematically assess and evaluate the preparedness status of each MMRS city and understand the effectiveness of the overall program approach. This proposed assessment and evaluation effort will focus on identifying changes that will improve and sustain the MMRS initiative, making it a more effective program that assists local health, medical and emergency systems to develop integrated effective responses to Weapons of Mass Destruction (WMD) events.

Plan of Action

The Institute of Medicine (IOM) will establish a committee to address the expressed need of the Department of Health and Human Services for a means of systematically assessing and evaluating the status of 72 or more Metropolitan Medical Response Systems developed by cities across the United States and understanding the effectiveness of the overall program approach. The committee of 15 will include expertise in public health, medicine, emergency response, emergency management, emergency planning, mental health, hospital administration, community planning and evaluation, and program and systems evaluation.

The project is divided into two (2) phases. In Phase I the committee will identify performance measures and systems to assess the effectiveness of, and identify barriers related to, the MMRS development process at the site, jurisdictional and governmental levels. In so doing, the committee will include the following considerations:

1. How can Office of Emergency Preparedness (OEP) measure, at the program level, whether the strategies, resources, mechanisms, technical assistance, and monitoring processes provided to the NMRS development process are effective?
2. How can OEP identify whether the performance objectives identified in the MMRS contract lead communities to preparedness?
3. What modifications, additions and/or subtractions should be made to these performance objectives to assist communities throughout the development process?
4. How can existing standards he used to validate these Performance objectives? If standards don't exist, how can new standards he created and/or the performance objectives be validated?
5. What strategies have communities used to enhance their existing capabilities? What are the most effective means to measure these additional capabilities?
6. Can relationships between traditional first responders / public safety officials and their supporting hospitals / public health offices be assessed? If so, how?
7. What tools and/or models exist to measure preparedness for natural disasters?
8. Do current Federal performance measures for natural disasters or other programs (mitigation and response) have application to WMD terrorism preparedness (e.g. FEMA Project IMPACT)?
9. How can casualty assumptions, for communities of varying populations, be established (percent of population, historical data)?
10. How can OEP measure the pre-existing systems, methodologies and plans that are used by public safety, public health and health services agencies to communicate during day to day operations? How can OEP measure the impact the MMRS development process has had on the level and/or expectations for this communication?
11. How can financial barriers related to WMD preparedness be identified and measured?

In Phase II the committee will use the performance measures developed from Phase I to recommend, then develop appropriate evaluation methods, tools, and processes to assess the MMRS development process. When developing these methods, tools and processes the committee will, at a minimum, address the following:

1. What is the most appropriate approach or model for evaluating the MMRS development process (e.g. surveys, interviews, review of plans, peer review, operational tests, etc.)?
2. Is there an appropriate sample size that would adequately represent the impact of the MMRS development process?
3. Considering the variance in local health systems, how can OEP appropriately draw meaningful conclusions from the results of this evaluation?

The evaluation system(s) developed will allow timely assessment of each deliverable or phase of the MMRS development process, emphasizing identification of barriers and solutions, and sharing successes of both the technical and administrative components of the MMRS program.

The committee will meet 5 times, 2 days on each occasion, in the course of the 18-month study. An initial largely organizational meeting will be held approximately 6 weeks after the study is initiated. This meeting will focus on clarifying the expectations of the sponsor, modifying the workplan if necessary, identifying topics and areas of performance appropriate to individual committee members, and planning data–gathering activities necessary for phase I of the project. If it is possible to do so without delaying the project, the second meeting will be held in conjunction with a site visit to, or a practical exercise or other operational experience conducted at, a representative MMRS city. The second meeting itself will center on preliminary identification of necessary performances and potential performance measures. OEP Headquarters staff, HHS Regional project officers and officials from MMRS development sites will be invited to assist the committee to gain better understanding of the program and its local, regional and national impact. The goal of the third meeting will be production of a letter report identifying recommended performance measures. The fourth and fifth meetings will center on developing appropriate evaluation tools and processes for use by OEP in future evaluation of the MMRS development and production of a suitable final report.