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entitled 'Hospital Preparedness: Most Urban Hospitals Have Emergency 
Plans but Lack Certain Capacities for Bioterrorism Response' which was 
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Report to Congressional Committees:

United States General Accounting Office:

GAO:

August 2003:

HOSPITAL PREPAREDNESS:

Most Urban Hospitals Have Emergency Plans but Lack Certain Capacities 
for Bioterrorism Response:

GAO-03-924:

GAO Highlights:

Highlights of GAO-03-924, a report to the Senate Committee on Health, 
Education, Labor, and Pensions; the Senate and House Committees on 
Appropriations; and the House Committee on Energy and Commerce

Why GAO Did This Study:

In the event of a large-scale infectious disease outbreak, as could be 
seen with a bioterrorist attack, hospitals and their emergency 
departments would be on the front line. Federal, state, and local 
officials are concerned, however, that hospitals may not have the 
capacity to accept and treat a sudden, large increase in the number of 
patients, as might be seen in a bioterrorist attack. In the Public 
Health Improvement Act that was passed in 2000, Congress directed GAO 
to examine preparedness for a bioterrorist attack. In this report GAO 
provides information on the extent of bioterrorism preparedness among 
hospitals in urban areas in the United States.

To conduct this work, GAO surveyed over 2,000 urban hospitals and 
about 73 percent provided responses addressing emergency preparedness. 
The survey collected information on hospital preparedness for 
bioterrorism, such as data on planning activities, staff training, and 
capacity for response.

What GAO Found: 

While most urban hospitals across the country reported participating 
in basic planning and coordination activities for bioterrorism 
response, they did not have the medical equipment to handle the number 
of patients that would be likely to result from a bioterrorist 
incident. Four out of five hospitals reported having a written 
emergency response plan addressing bioterrorism, but many plans 
omitted some key contacts, such as other laboratories. Almost all 
hospitals reported participating in a local, state, or regional 
interagency disaster preparedness committee. In addition, most 
hospitals reported having provided at least some training to their 
personnel on identification and diagnosis of disease caused by 
biological agents considered likely to be used in a bioterrorist 
attack, such as anthrax or botulism. In contrast, fewer than half of 
hospitals have conducted drills or exercises simulating response to a 
bioterrorist incident. Hospitals also reported that they lacked the 
medical equipment necessary for a large influx of patients. For 
example, if a large number of patients with severe respiratory 
problems associated with anthrax or botulism were to arrive at a 
hospital, a comparable number of ventilators would be required to 
treat them. Yet half of hospitals reported having fewer than six 
ventilators per 100 staffed beds. In general, larger hospitals 
reported more planning and training activities than smaller hospitals.

Representatives from the American Hospital Association provided oral 
comments on a draft of this report, which GAO incorporated as 
appropriate.  They generally agreed with the findings.

www.gao.gov/cgi-bin/getrpt?GAO-03-924.

To view the full product, including the scope and methodology, click 
on the link above. For more information, contact Marcia Crosse on 
(202) 512-7119.

[End of section]

Contents:

Lette1:

Results in Brief:

Background:

Hospitals Reported Planning for Bioterrorism Response but Do Not Have 
Certain Medical Capacities to Handle a Large Increase in Patient Load:

Concluding Observations:

Comments from the American Hospital Association:

Appendix I: Selected Results of GAO Survey of Hospitals Regarding 
Hospital Preparedness for Bioterrorism:

Appendix II: Scope and Methodology:

Appendix III: GAO Contact and Staff Acknowledgments:

GAO Contact:

Acknowledgments:

Related GAO Products:

Tables:

Table 1: Percentage of Urban Hospitals Participating in an Interagency 
Disaster Preparedness Committee That Also Includes Members from 
Specified Organization:

Table 2: Urban Hospitals with Medical Equipment Capabilities, per 100 
Staffed Beds:

Table 3: Characteristics of Hospitals in Survey:

Table 4: Number of Hospitals That Were Sent Survey, Number That 
Responded to Survey, and Percentage of Hospitals That Responded to 
Survey, by State and District of Columbia:

Table 5: Percentage of Urban Hospitals with a Written Emergency 
Response Plan Addressing Bioterrorism, by State:

Table 6: Percentage of Urban Hospitals That Reported Specifying in 
Emergency Response Plan to Contact the Specified Entities during an 
Emergency, by State:

Table 7: Percentage of Urban Hospitals Whose Mass Casualty Plans 
Address Bioterrorism and Describe How to Manage the Specified Function, 
by State:

Table 8: Percentage of Urban Hospitals That Had Agreements with Other 
Hospitals or City, County, State, and Regional Organizations to Provide 
or Share Resources in the Event of Bioterrorism, by State:

Table 9: Percentage of Urban Hospitals That Have Provided Training to 
Staff (Services, Courses, or Self-Learning Materials) to Identify and 
Diagnose Symptoms for the Following Biological Agents, by State:

Table 10: Percentage of Urban Hospitals That Participated in Mass 
Casualty Drills Related to Biological Incidents by State:

Figures:

Figure 1: Percentage of Urban Hospitals with a Written Emergency 
Response Plan Addressing Bioterrorism:

Figure 2: Percentage of Urban Hospitals That Reported Specifying in 
Emergency Response Plan to Contact the Specified Entity during an 
Emergency:

Figure 3: Percentage of Urban Hospitals Whose Emergency Response Plans 
Addressed Bioterrorism and Included a Description of How to Manage the 
Specified Function:

Figure 4: Percentage of Urban Hospitals That Have Agreements with Other 
Hospitals or City, County, State, or Regional Organizations to Provide 
or Share Resources in the Event of Bioterrorism:

Figure 5: Percentage of Urban Hospitals That Have Provided Staff with 
Training (Services, Courses, or Self-Learning Materials) about 
Identifying and Diagnosing Symptoms for Each of the Following 
Biological Agents:

Abbreviations:

EMS: emergency medical services:  

HAZMAT: hazardous materials:  

HHS: Department of Health and Human Services:  

HRSA: Health Resources and Services Administration:  

MSA: metropolitan statistical area:  

PPE: personal protective equipment:  

SARS: Severe Acute Respiratory Syndrome:

United States General Accounting Office:

Washington, DC 20548:

August 6, 2003:

Congressional Committees:

In the event of a large-scale infectious disease outbreak, as could be 
seen with a bioterrorist attack, hospitals and their emergency 
departments would be on the front line. The release of a biological 
agent by a terrorist might not be recognized for several days, during 
which time a communicable disease could be spread to many people who 
were not initially exposed. Because hospitals are open 24 hours a day, 
7 days a week, victims would be likely to seek treatment of their 
symptoms there, putting hospital personnel in the role of first 
responders. Federal, state, and local officials are concerned, however, 
that hospitals may not have the capacity to accept and treat a sudden, 
large increase in the number of patients, as might be seen in a 
bioterrorist attack.[Footnote 1] For example, these officials are 
concerned that this surge in patients would be likely to overwhelm 
emergency departments in urban areas, many of which are already 
operating at or above capacity.[Footnote 2]

The Public Health Improvement Act directed that we examine state and 
local levels of preparedness for a bioterrorist attack.[Footnote 3] We 
have previously reported on activities by federal agencies and state 
and local public health agencies and health care organizations, 
including hospitals, to prepare for and respond to 
bioterrorism.[Footnote 4] In this report we are providing you with 
additional information on the extent of bioterrorism preparedness among 
urban hospitals in the United States, specifically with respect to 
planning activities, staff training, and capacity for response.

To obtain information on the extent of hospital bioterrorism 
preparedness, we conducted a survey between May and September 2002 of 
2,041 urban hospitals across the country that have emergency 
departments. (See app. I for a description of the hospitals we 
surveyed.) The survey asked questions relating to emergency room 
functioning and hospital bioterrorism preparedness. We reported our 
survey findings on emergency room functioning in March 2003.[Footnote 
5] We obtained responses to the survey addressing bioterrorism 
preparedness from 1,482 hospitals, for a response rate of 73 percent 
and we are providing our survey findings in the current report. The 
survey covered key components of hospital preparedness for 
bioterrorism, including planning activities related to communication 
and coordination with community and state organizations (e.g., 
participation in an interagency disaster preparedness committee); staff 
training; and the response capacity of the facility (e.g., number of 
isolation beds) and of the equipment (e.g., number of 
ventilators[Footnote 6]). We weighted responses to adjust for a lower 
response rate from investor-owned (for-profit) hospitals to provide 
estimates representative of the entire universe of urban hospitals we 
surveyed. Our report reflects hospital preparedness at the time of our 
survey in 2002. Improvements in hospital preparedness may have occurred 
since these data were collected. (For more detail on our scope and 
methodology, see app. II.) We did our work from May 2002 through July 
2003 in accordance with generally accepted government auditing 
standards.

Results in Brief:

While most hospitals in urban areas across the country reported 
participating in basic planning and coordination activities for 
bioterrorism response, they did not have the medical equipment to 
handle the large increase in the number of patients that would be 
likely to result from a bioterrorist incident. Four out of five 
hospitals reported having a written emergency response plan addressing 
bioterrorism, but many plans omitted some key contacts, such as 
laboratories outside the hospital. Almost all hospitals reported 
participating in a local, state, or regional interagency disaster 
preparedness committee. In addition, most hospitals reported having 
provided at least some training to their personnel on identification 
and diagnosis of disease caused by biological agents considered likely 
to be used in a bioterrorist attack, such as anthrax or botulism. In 
contrast, fewer than half of hospitals have conducted drills or 
exercises simulating response to a bioterrorist incident. Hospitals 
also reported that they lacked the medical equipment necessary for a 
large influx of patients. For example, if a large number of patients 
were to arrive at a hospital with severe respiratory problems 
associated with anthrax or botulism, a comparable number of ventilators 
would be required to treat them. Yet half of hospitals reported having 
fewer than six ventilators per 100 staffed beds. In general, larger 
hospitals reported more planning and training activities than smaller 
hospitals.

Representatives of the American Hospital Association provided oral 
comments on a draft of this report, which we incorporated as 
appropriate. They generally agreed with our findings.

Background:

The resources that hospitals and their emergency departments would 
require for responding to a large-scale bioterrorist attack are far 
greater than those needed for everyday performance. The specific 
equipment, supplies, and facilities needed could vary depending upon 
what type of attack occurred, but many scenarios anticipate that the 
demand for health care could quickly outstrip the ability of hospitals 
to respond. For example, the TOPOFF 2000 exercise[Footnote 7] testing 
terrorism preparedness included a bioterrorism scenario of an attack 
using pneumonic plague[Footnote 8] released at a public event in a 
single location in one city. In this exercise, officials found that by 
the third day following the covert release, 500 persons with symptoms 
had been reported and antibiotic and ventilator shortages were 
beginning to occur. By the end of this day, nearly 800 cases were 
identified and over 100 persons had died. In each of the succeeding 2 
days, the situation worsened and medical care in the city was described 
as beginning to shut down, with insufficient hospital staff, beds, 
ventilators, and drugs. At the conclusion of the exercise, 1 week after 
the attack, an estimated 3,700 cases of plague had been reported, with 
950 to 2,000 deaths, including cases in other cities and abroad. In the 
early stages of the epidemic, hospitals were seeing 2 to 3 times their 
normal volume of patients and later in the exercise up to 10 times 
normal volumes were arriving at hospitals. Hospitals were not able to 
effectively isolate patients to prevent the spread of the disease to 
hospital staff.

In order to be adequately prepared for bioterrorism, hospitals would 
need to have several basic capabilities, whether they possess them 
directly or have access to them through regional agreements. Plans that 
describe how hospitals would work with state and local officials to 
manage and coordinate an emergency response would need to be in place 
and to have been tested in an exercise, both at the state and local 
levels and at the regional level. Regional plans can help address 
capacity deficiencies by providing for the sharing, among hospitals and 
other community and state agencies and organizations, of resources 
that, while adequate for everyday needs, may be in short supply on a 
local level in an emergency. In addition, hospitals would need to be 
able to communicate easily with all organizations involved in the 
response as events unfold and critical information is acquired. Staff 
would need to be able to recognize and report to their state or local 
health department any illness patterns or diagnostic clues that might 
indicate an outbreak of a disease caused by a biological agent likely 
to be used by a terrorist.[Footnote 9] Finally, hospitals would need to 
have the capacity and staff necessary to treat large numbers of 
severely ill patients and limit the spread of infectious disease. They 
would need adequate stores of equipment and supplies, including 
medications, personal protective equipment, quarantine and isolation 
facilities,[Footnote 10] and air handling and filtration equipment.

Many of the capabilities required for responding to a large-scale 
bioterrorist attack are also required for response to naturally 
occurring disease outbreaks. Such a "dual-use" response infrastructure 
improves the capacity of local public health agencies to respond to all 
hazards. For example, a large-scale outbreak of Severe Acute 
Respiratory Syndrome (SARS) would require many of the same capabilities 
that would be needed to respond to an intentionally caused 
epidemic.[Footnote 11]

Prior to our survey, efforts had been made by organizations to assist 
hospitals in preparing for bioterrorism. For example, the American 
Hospital Association distributed a checklist to help hospitals describe 
and assess their state of preparedness for chemical and biological 
incidents.[Footnote 12] This checklist covered, for example, emergency 
response plans for hospital operations during a biological or chemical 
disaster; emergency preparedness training of the workers; and the 
hospital's ability to increase its capacity--for example, in terms of 
such items as ventilators and decontamination equipment--in the event 
of a large number of patients seeking care. Another organization, the 
Association for Professionals in Infection Control and Epidemiology, 
developed a mass casualty disaster plan checklist for health care 
facilities, including hospitals.[Footnote 13] This checklist included 
disease surveillance activities,[Footnote 14] communication systems, 
plans for receiving and treating casualties, and plans for the 
organized discharge of nonemergency patients on short notice.

Nevertheless, in our April 2003 report,[Footnote 15] we noted the 
general lack of guidance on what capacities hospitals should have to be 
prepared for bioterrorism. We also noted that efforts to improve 
hospitals' bioterrorism response capacities must be mindful that 
hospitals face multiple challenges, including having to prepare for 
other types of disasters and continuing to meet the everyday needs of 
cities for emergency care. In that report, among other things, we 
recommended that the Department of Health and Human Services (HHS) 
develop specific benchmarks that define adequate preparedness for a 
bioterrorist attack and can be used to guide preparedness efforts.

Since our survey, there have been continuing efforts to assist 
hospitals in bioterrorism preparedness. For example, the Joint 
Commission on Accreditation of Healthcare Organizations released a 
report in 2003 on strategies for creating and sustaining communitywide 
preparedness systems for health care organizations, including 
hospitals.[Footnote 16] The report outlined critical issues to be 
addressed in developing communitywide preparedness and discussed 
federal and state responsibilities for eliminating barriers to 
preparedness and for facilitating and sustaining hospital and 
community-based emergency preparedness. It called for hospitals to 
address the full range of potential disasters, including terrorism, in 
their planning and to be aware of the specific hazards applicable to 
their communities.

The federal government has also provided assistance for improving the 
bioterrorism preparedness of hospitals. In January 2002 HHS announced 
the availability of funding for that purpose.[Footnote 17] The 
Bioterrorism Hospital Preparedness Program, administered by HHS's 
Health Resources and Services Administration (HRSA), provided funding 
in fiscal year 2002 of approximately $125 million through cooperative 
agreements to states and eligible municipalities to enhance the 
capacity of hospitals and associated health care entities to respond to 
bioterrorism.[Footnote 18]

These noncompetitive cooperative agreements covered two phases. In the 
first phase, states and municipalities applying for this funding were 
required to develop a needs assessment for a comprehensive bioterrorism 
preparedness program for hospitals and other health care entities, such 
as community health centers, and an implementation plan, as well as to 
begin initial implementation of the plan. Applications for the first 
phase were due to HHS by February 25, 2002, and funding for this phase, 
approximately $25 million, was awarded shortly after receipt of 
applications. For the second phase, jurisdictions were required to 
submit more detailed implementation plans, in which they addressed 
three "critical benchmarks," including a regional hospital plan for 
dealing with a potential epidemic involving at least 500 patients. In 
addition, applicants were to address four top-priority planning areas: 
medications and vaccines; personal protection, quarantine, and 
decontamination; communications; and biological disaster drills. 
Applications for the second phase were due April 15, 2002, and the 
additional funding, approximately $100 million, was awarded after HHS's 
review and approval of the plans. In March 2003, HHS announced that 
HRSA's National Bioterrorism Hospital Preparedness Program would 
provide funding in fiscal year 2003 of approximately $498 million 
through cooperative agreements to states and eligible 
municipalities.[Footnote 19] In response to our recommendations 
concerning additional guidance, HHS noted that it is developing some 
additional guidelines and templates to assist in preparedness 
efforts.[Footnote 20]

In addition, the federal government has established a stockpile of 
pharmaceuticals, antidotes, and medical supplies that can be delivered 
to the site of a bioterrorist (or other) attack. This Strategic 
National Stockpile has recently been expanded and HHS disclosed that it 
is planning to purchase 2,700 ventilators by September 2003 to 
supplement those now available in the stockpile. These supplies could 
be deployed to the site of an attack within 12 to 36 hours following a 
declaration of an emergency.

Hospitals Reported Planning for Bioterrorism Response but Do Not Have 
Certain Medical Capacities to Handle a Large Increase in Patient Load:

Most hospitals in urban areas across the country reported participating 
in basic planning and coordination activities for bioterrorism 
response. Although most hospitals reported providing at least some 
training to their personnel on identification and diagnosis of disease 
caused by biological agents considered likely to be used in a 
bioterrorist attack, only about half report they have conducted drills 
or exercises simulating response to a bioterrorist incident. Further, 
few reported having acquired the medical equipment to handle the large 
increase in the number of patients that would be likely to result from 
a bioterrorist incident.

Most Hospitals Have Emergency Response Plans Addressing Bioterrorism 
and Are Participating in Local, State, or Regional Planning and 
Coordination Activities:

Our survey showed that hospitals have engaged in a variety of planning 
and coordination activities, with most having prepared an emergency 
response plan addressing bioterrorism; participated in a local, state, 
or regional interagency disaster preparedness committee; and made 
agreements with at least one other organization to share personnel or 
equipment in the event of a bioterrorist or other mass casualty 
incident.

Four out of five hospitals reported having a written emergency response 
plan that specifically addresses bioterrorism (see fig. 1). Hospitals 
that had a plan were on average around 15 percent larger than those 
that did not in terms of number of staffed beds.[Footnote 21] Of those 
hospitals that reported not having such a plan, almost all were 
currently developing one.

Figure 1: Percentage of Urban Hospitals with a Written Emergency 
Response Plan Addressing Bioterrorism:

[See PDF for image]

Note: Data are from our 2002 survey of hospitals and their emergency 
departments. Responses were weighted to provide estimates for the 
universe of hospitals.

[End of figure]

We asked hospitals whether certain elements were specified in their 
emergency response plan: contacting other response agencies and 
organizations in the event of a bioterrorist incident and managing 
various critical functions such as decontamination of victims. As shown 
in figure 2, of the hospitals that reported having an emergency 
response plan for bioterrorism, approximately 90 percent reported 
specifying in their plan to contact state and local government 
agencies, public health agencies, other hospitals, hazardous materials 
(HAZMAT) teams, emergency medical services (EMS), fire departments, or 
law enforcement. These entities would be critical to mounting a larger 
communitywide response, communicating with the public, investigating 
and controlling sources of the outbreak, transporting patients, 
maintaining order, and investigating those responsible for the 
bioterrorism. Hospitals that planned to contact HAZMAT teams or public 
health agencies were on average around 15 and 20 percent larger, 
respectively, than those that did not. There were no significant 
differences in average sizes of hospitals with respect to contacting 
any of the other entities. Approximately 75 percent of hospitals 
reported planning to contact public or private utilities, whose 
assistance could be needed to increase or maintain power supplies to 
critical equipment or to control water-or sewer-borne pathogens. 
Although establishing contact with other laboratories that could 
potentially provide additional capacity for overstretched hospital 
laboratories would be critical, the percentage of hospitals planning to 
make that link was lowest, at approximately 60 percent. Approximately 
40 percent of hospitals reported specifying contacting all nine types 
of entities listed in figure 2.

Figure 2: Percentage of Urban Hospitals That Reported Specifying in 
Emergency Response Plan to Contact the Specified Entity during an 
Emergency:

[See PDF for image]

Note: Data are from our 2002 survey of hospitals and their emergency 
departments. Responses were weighted to provide estimates for the 
universe of hospitals. Data are presented for hospitals that reported 
having an emergency response plan that addresses bioterrorism.

[End of figure]

As shown in figure 3, most of the hospitals that reported having an 
emergency response plan for bioterrorism indicated that they specified 
in that plan how certain critical functions were to be managed. The 
functions specified by more than 87 percent of hospitals included 
providing for hospital security to control entry to and exit from all 
parts of the hospital; obtaining additional staff, supplies, and 
pharmaceuticals to increase the hospital's capacity to handle a surge 
of patients; or planning for mass evacuation of nonemergency patients 
on short notice. In general, larger hospitals had emergency response 
plans that covered more of these functions than the plans of smaller 
hospitals. Hospitals that reported addressing how to obtain additional 
pharmaceuticals for surge capacity, "worried well"[Footnote 22] 
management, and mass fatalities were on average around 15 percent 
larger than those that did not. There were no significant differences 
in average sizes of hospitals with respect to any of the other 
functions. Approximately 77 percent of the hospitals reported 
addressing the question of how to manage a large influx of the worried 
well and distinguish them from victims who may be in the early stages 
of illness. Approximately 50 percent of hospitals addressed the 
management of all of the critical functions listed in figure 3.

Figure 3: Percentage of Urban Hospitals Whose Emergency Response Plans 
Addressed Bioterrorism and Included a Description of How to Manage the 
Specified Function:

[See PDF for image]

Note: Data are from our 2002 survey of hospitals and their emergency 
departments. Responses were weighted to provide estimates for the 
universe of hospitals. Data are presented for hospitals that reported 
having an emergency response plan that addressed bioterrorism.

[End of figure]

Whether they had an emergency response plan addressing bioterrorism or 
not, more than 95 percent of hospitals reported participating in a 
local, state, or regional interagency disaster preparedness committee, 
task force, or working group. Most commonly, these committees also 
included representatives from city and county emergency medical 
services organizations, fire departments, city and county offices of 
emergency management, other local hospitals or medical institutions, 
city and county public health or health departments and agencies, and 
law enforcement organizations (see table 1). As we have previously 
reported,[Footnote 23] it was not until after September 11, 2001, that 
government and hospital officials came to view hospitals as an integral 
component in local planning for responding to a terrorist event.

Table 1: Percentage of Urban Hospitals Participating in an Interagency 
Disaster Preparedness Committee That Also Includes Members from 
Specified Organization:

City and county emergency medical services organizations; Percentage: 
94.0.

Fire departments; Percentage: 91.2.

City and county offices of emergency management; Percentage: 88.3.

Other local hospitals or other medical institutions; Percentage: 86.8.

City and county public health or health departments and agencies; 
Percentage: 86.6.

Law enforcement organizations; Percentage: 84.0.

State health or public health departments and agencies; Percentage: 
47.0.

Professional organizations (e.g., emergency medicine organization, 
local medical society, hospital association); Percentage: 46.6.

State office of emergency management; Percentage: 46.6.

Surrounding area mutual aid response organizations; Percentage: 43.9.

Public or private utilities (such as water and power); Percentage: 
37.6.

State law enforcement organizations; Percentage: 36.7.

Board of supervisors or other elected officials; Percentage: 34.4.

Freestanding HAZMAT organizations; Percentage: 33.2.

Public or private transportation organizations; Percentage: 31.1.

State office of emergency medical services; Percentage: 29.8.

Federal Bureau of Investigation; Percentage: 24.8.

Federal Emergency Management Agency; Percentage: 21.2.

National Guard; Percentage: 18.3.

Centers for Disease Control and Prevention; Percentage: 11.3.

State office of fire control; Percentage: 10.7.

Department of Justice; Percentage: 8.4.

Source: GAO.

Note: Data are from our 2002 survey of hospitals and their emergency 
departments. Responses were weighted to provide estimates for the 
universe of hospitals. Data are presented for hospitals that reported 
participating on an interagency disaster preparedness committee, task 
force, or working group.

[End of table]

Another planning and coordination activity that hospitals reported on 
in our survey was their participation in agreements to share or provide 
resources in the event of a bioterrorist or other mass casualty 
incident. We asked about agreements at the hospital, city, county, 
state, and regional levels. The survey results indicated that hospitals 
mostly coordinated with other hospitals, about half coordinated with 
the local government, and about one-third coordinated at the state or 
regional level to provide or share resources. About 70 percent of 
hospitals reported that they had agreements, such as memoranda of 
understanding or mutual aid agreements, with other hospitals to provide 
or share personnel, equipment, or other resources (see fig. 4). Fewer 
(between 37 and 54 percent) hospitals had agreements with regional, 
state, county, or city organizations (fig. 4). In general, hospitals 
that had agreements with other organizations were larger than those 
that did not. Hospitals that had agreements with other hospitals or 
with city organizations were on average around 10 percent larger than 
hospitals that did not. Fewer than 20 percent of hospitals had 
agreements with entities at all five levels.

Figure 4: Percentage of Urban Hospitals That Have Agreements with Other 
Hospitals or City, County, State, or Regional Organizations to Provide 
or Share Resources in the Event of Bioterrorism:

[See PDF for image]

Note: Data are from our 2002 survey of hospitals and their emergency 
departments. Responses were weighted to provide estimates for the 
universe of hospitals.

[End of figure]

Staff Training on Biological Agents Was Reported to Be Widespread, 
While Hospital Participation in Drills Was Less Common:

Approximately 7 out of 10 hospitals reported that their staff had 
received training (services, courses, or self-learning materials) for 
identifying and diagnosing illness caused by all six biological agents 
that CDC has stated would be most likely to be used in a bioterrorist 
incident (see fig. 5). Hospitals that reported training activities for 
all of the biological agents were on average around 15 percent larger 
than hospitals that did not. A greater percentage of hospitals reported 
that staff had received training for anthrax or smallpox (around 90 
percent or more) than for plague or botulism (approximately 80 percent) 
or tularemia or hemorrhagic fever viruses (approximately 70 percent). 
However, the extensiveness of the reported training cannot be 
determined from our survey.

Figure 5: Percentage of Urban Hospitals That Have Provided Staff with 
Training (Services, Courses, or Self-Learning Materials) about 
Identifying and Diagnosing Symptoms for Each of the Following 
Biological Agents:

[See PDF for image]

Note: Data are from our 2002 survey of hospitals and their emergency 
departments. Responses were weighted to provide estimates for the 
universe of hospitals.

[End of figure]

About half of all hospitals reported participating in drills or 
tabletop exercises simulating a biological attack during the past 2 
years.[Footnote 24] Hospitals that reported participating in biological 
drills were on average around 20 percent larger than hospitals that did 
not. Of all of the hospitals that participated in biological drills or 
exercises, approximately 80 percent carried out these activities with 
other organizations.

Hospitals Reported Insufficient Medical Equipment to Handle a Large 
Increase in Patients:

The availability of medical equipment needed for bioterrorism response 
varied greatly among hospitals, and hospitals reported that they did 
not have the capacity to respond to the large increase in the number of 
patients that would be likely to result from a bioterrorist incident 
with mass casualties (see table 2). For example, if a large number of 
patients were to arrive at a hospital with severe respiratory problems 
associated with anthrax or botulism, a comparable number of ventilators 
would be required to treat them. However, half of the hospitals had, 
per 100 staffed beds, fewer than six ventilators, three or fewer 
personal protective equipment (PPE) suits, fewer than four isolation 
beds, or the ability to handle fewer than six patients per hour through 
a 5-minute decontamination shower. More specifically, fewer than 31 
percent of hospitals could handle 10 or more patients per hour through 
a 5-minute decontamination shower per 100 staffed beds, and fewer than 
10 percent had 10 or more isolation beds per 100 staffed beds. Almost 
40 percent of the hospitals had fewer than two PPE suits per 100 
staffed beds, and almost 10 percent had fewer than two ventilators per 
100 staffed beds. Hospital officials have told us that bioterrorism 
preparedness is expensive and they are reluctant to create capacity 
that is not needed on a routine basis and may never be needed at a 
particular facility.[Footnote 25]

Table 2: Urban Hospitals with Medical Equipment Capabilities, per 100 
Staffed Beds:

Ventilators:

Less than 2 ventilators; Percentage of hospitals: Ventilators: 9.0.

2 to less than 5 ventilators; Percentage of hospitals: Ventilators: 
33.9.

5 to less than 10 ventilators; Percentage of hospitals: Ventilators: 
39.7.

10 or more ventilators; Percentage of hospitals: Ventilators: 17.4.

Total percentage of hospitals: Ventilators: 100.

Personal protective equipment (PPE) suits:

Less than 2 PPE suits; Percentage of hospitals: Ventilators: 38.2.

2 to less than 5 PPE suits; Percentage of hospitals: Ventilators: 24.8.

5 to less than 10 PPE suits; Percentage of hospitals: Ventilators: 
16.6.

10 or more PPE suits; Percentage of hospitals: Ventilators: 20.3.

Total percentage of hospitals: Ventilators: 100[A].

Isolation beds:

Less than 2 isolation beds; Percentage of hospitals: Ventilators: 18.6.

2 to less than 5 isolation beds; Percentage of hospitals: Ventilators: 
47.3.

5 to less than 10 isolation beds; Percentage of hospitals: Ventilators: 
24.6.

10 or more isolation beds; Percentage of hospitals: Ventilators: 9.5.

Total percentage of hospitals: Ventilators: 100.

Number of patients per hour through 5 minute decontamination shower:

Less than 2 patients per hour; Percentage of hospitals: Ventilators: 
15.3.

2 to less than 5 patients per hour; Percentage of hospitals: 
Ventilators: 25.8.

5 to less than 10 patients per hour; Percentage of hospitals: 
Ventilators: 28.4.

10 or more patients per hour; Percentage of hospitals: Ventilators: 
30.5.

Total percentage of hospitals: Ventilators: 100.

Source: GAO.

Note: Data are from our 2002 survey of hospitals and their emergency 
departments. Responses were weighted to provide estimates for the 
universe of hospitals.

[A] Does not total to 100 percent due to rounding.

[End of table]

Concluding Observations:

As concerns about bioterrorism have intensified over the past few 
years, hospitals across the nation have been working to increase their 
preparedness for responding to such events. The staff and equipment 
that hospitals would require to respond to a bioterrorist attack with 
mass casualties are far greater than what are needed for everyday 
performance. Meeting those needs fully could be extremely difficult 
because bioterrorism preparedness is expensive and hospitals are 
reluctant to create capacity that is not needed on a routine basis and 
may never be used. In addition, along with a hospital's ability to meet 
the routine needs of the community, needs for additional capacity for 
responding to bioterrorism emergencies must be balanced with the need 
to be prepared for all types of emergencies. Hospital officials have 
recognized that their facilities are an essential component of our 
nation's bioterrorism preparedness and have begun planning and training 
efforts to increase their response capacity. Most hospitals, however, 
still lack equipment, medical stockpiles, and quarantine and isolation 
facilities for even a small-scale response. The additional funding that 
is to be provided under the National Bioterrorism Hospital Preparedness 
Program in fiscal year 2003 can be used to help hospitals address these 
issues. The additional guidance from HHS, in response to our earlier 
recommendations, may also be helpful in assisting hospitals to better 
determine what specific response capacities they need to ensure.

Comments from the American Hospital Association:

Representatives from the American Hospital Association provided oral 
comments on a draft of this report. The officials generally agreed with 
our findings and stated that this was a good and useful report 
providing helpful information on hospital preparedness. They commended 
us for the high response rate to the survey, stating that this provided 
a more comprehensive picture of hospital activities than was available 
elsewhere. The officials suggested that the report make greater 
reference to the lack of specific benchmarks for hospitals to use in 
planning, provide additional context on the range of possible events 
that hospitals must consider in their planning, and refer readers more 
specifically to prior GAO recommendations on bioterrorism preparedness. 
We have added additional material to clarify these points. The 
officials also provided technical remarks, which we have incorporated 
where appropriate.

We are sending copies of this report to the Secretary of HHS, the 
Administrator of HRSA, and other interested officials. We will also 
provide copies to others upon request. In addition, the report will be 
available at no charge on GAO's Web site at http://www.gao.gov.

If you or your staffs have any questions about this report, please call 
me at (202) 512-7119. Key contributors are listed in appendix III.

Marcia Crosse 

Acting Director, Health Care--Public Health and Science Issues:

Signed by Marcia Crosse: 

List of Committees:

The Honorable Judd Gregg 
Chairman 
The Honorable Edward M. Kennedy 
Ranking Minority Member 
Committee on Health, Education, Labor, and Pensions 
United States Senate:

The Honorable Ted Stevens 
Chairman 
The Honorable Robert C. Byrd 
Ranking Minority Member 
Committee on Appropriations 
United States Senate:

The Honorable W.J. "Billy" Tauzin 
Chairman 
The Honorable John D. Dingell 
Ranking Minority Member 
Committee on Energy and Commerce 
House of Representatives:

The Honorable C.W. Bill Young 
Chairman 
The Honorable David Obey 
Ranking Minority Member 
Committee on Appropriations 
House of Representatives:

[End of section]

Appendix I: Selected Results of GAO Survey of Hospitals Regarding 
Hospital Preparedness for Bioterrorism:

This appendix describes the characteristics of the short-term, 
nonfederal, general medical and surgical hospitals in metropolitan 
statistical areas (MSA) in the United States that had emergency 
departments in 2000 that we surveyed, and summarizes results by state. 
We sent the questionnaires to 2,041 hospitals that met these criteria-
-20 did not have emergency departments in fiscal year 2001 or were 
closed, for a total of 2,021 hospitals. We obtained responses to the 
survey from 1,489 hospitals, for an overall response rate of about 74 
percent. However, 7 of these hospitals did not return the section of 
the survey addressing emergency preparedness, leaving 1,482, for a 
response rate of about 73 percent for the questions of concern for the 
current report. We weighted responses to adjust for a lower response 
rate from investor-owned (for-profit) hospitals to provide estimates 
representative of the entire universe of 2,021 hospitals in MSAs.

The following tables show selected survey information on the 
characteristics of the survey universe (table 3), response rates for 
hospitals by state for all states and the District of Columbia (table 
4), planning and coordination activities (tables 5 through 8), and 
training activities (tables 9 and 10), for states that had at least 10 
hospitals respond and a response rate of at least 50 percent (tables 4-
10). All data in tables are weighted to provide estimates for the 
universe of 2,021 hospitals in MSAs.

Table 3: Characteristics of Hospitals in Survey:

Population of hospital's MSA: 

Population of hospital's MSA: 2.5 million or more; Number of 
hospitals: 545; Percentage: 27.

Population of hospital's MSA: 1 million to less than 2.5 million; 
Number of hospitals: 584; Percentage: 29.

Population of hospital's MSA: Less than 1 million; Number of 
hospitals: 892; Percentage: 44.

Total number of hospitals; Number of hospitals: 2,021; Percentage: 100.

Ownership type:

Private, not-for-profit; Number of hospitals: 1,460; Percentage: 72.

Investor-owned (for-profit); Number of hospitals: 311; Percentage: 15.

Public (nonfederal); Number of hospitals: 250; Percentage: 12.

Total number of hospitals; Number of hospitals: 2,021; Percentage: 100.

Teaching hospital.

Yes; Number of hospitals: 713; Percentage: 35.

No; Number of hospitals: 1,308; Percentage: 65.

Total number of hospitals; Number of hospitals: 2,021; Percentage: 100.

Number of staffed beds[A].

Less than 100; Number of hospitals: 311; Percentage: 16.

100 to less than 200; Number of hospitals: 617; Percentage: 31.

200 to less than 300; Number of hospitals: 453; Percentage: 22.

300 or more; Number of hospitals: 620; Percentage: 31.

Total number of hospitals; Number of hospitals: 2,021; Percentage: 100.

Source: GAO.

Note: Data are from our 2002 survey of hospitals and their emergency 
departments. Responses were weighted to provide estimates for the 
universe of hospitals. Percentages may not total 100 owing to rounding.

[A] Staffed beds are total facility beds set up and staffed at the end 
of the reporting period as reported by hospitals in the American 
Hospital Association Annual Survey Database 2000.

[End of table]

Table 4: Number of Hospitals That Were Sent Survey, Number That 
Responded to Survey, and Percentage of Hospitals That Responded to 
Survey, by State and District of Columbia:

State: Alabama; Number of hospitals that were sent surveys: 34; Number 
of hospitals that responded to survey: 24; Percentage of hospitals that 
responded to survey: 71.

State: Alaska; Number of hospitals that were sent surveys: 3; Number of 
hospitals that responded to survey: 2; Percentage of hospitals that 
responded to survey: 67.

State: Arizona; Number of hospitals that were sent surveys: 27; Number 
of hospitals that responded to survey: 19; Percentage of hospitals that 
responded to survey: 70.

State: Arkansas; Number of hospitals that were sent surveys: 21; Number 
of hospitals that responded to survey: 15; Percentage of hospitals that 
responded to survey: 71.

State: California; Number of hospitals that were sent surveys: 173; 
Number of hospitals that responded to survey: 109; Percentage of 
hospitals that responded to survey: 63.

State: Colorado; Number of hospitals that were sent surveys: 25; Number 
of hospitals that responded to survey: 19; Percentage of hospitals that 
responded to survey: 76.

State: Connecticut; Number of hospitals that were sent surveys: 24; 
Number of hospitals that responded to survey: 21; Percentage of 
hospitals that responded to survey: 88.

State: Delaware; Number of hospitals that were sent surveys: 1; Number 
of hospitals that responded to survey: 1; Percentage of hospitals that 
responded to survey: 100.

State: DC; Number of hospitals that were sent surveys: 7; Number of 
hospitals that responded to survey: 6; Percentage of hospitals that 
responded to survey: 86.

State: Florida; Number of hospitals that were sent surveys: 129; Number 
of hospitals that responded to survey: 89; Percentage of hospitals that 
responded to survey: 69.

State: Georgia; Number of hospitals that were sent surveys: 58; Number 
of hospitals that responded to survey: 41; Percentage of hospitals that 
responded to survey: 71.

State: Hawaii; Number of hospitals that were sent surveys: 6; Number of 
hospitals that responded to survey: 4; Percentage of hospitals that 
responded to survey: 67.

State: Idaho; Number of hospitals that were sent surveys: 5; Number of 
hospitals that responded to survey: 5; Percentage of hospitals that 
responded to survey: 100.

State: Illinois; Number of hospitals that were sent surveys: 106; 
Number of hospitals that responded to survey: 83; Percentage of 
hospitals that responded to survey: 78.

State: Indiana; Number of hospitals that were sent surveys: 52; Number 
of hospitals that responded to survey: 42; Percentage of hospitals that 
responded to survey: 81.

State: Iowa; Number of hospitals that were sent surveys: 20; Number of 
hospitals that responded to survey: 13; Percentage of hospitals that 
responded to survey: 65.

State: Kansas; Number of hospitals that were sent surveys: 19; Number 
of hospitals that responded to survey: 12; Percentage of hospitals that 
responded to survey: 63.

State: Kentucky; Number of hospitals that were sent surveys: 26; Number 
of hospitals that responded to survey: 21; Percentage of hospitals that 
responded to survey: 81.

State: Louisiana; Number of hospitals that were sent surveys: 58; 
Number of hospitals that responded to survey: 28; Percentage of 
hospitals that responded to survey: 48.

State: Maine; Number of hospitals that were sent surveys: 7; Number of 
hospitals that responded to survey: 5; Percentage of hospitals that 
responded to survey: 71.

State: Maryland; Number of hospitals that were sent surveys: 36; Number 
of hospitals that responded to survey: 26; Percentage of hospitals that 
responded to survey: 72.

State: Massachusetts; Number of hospitals that were sent surveys: 44; 
Number of hospitals that responded to survey: 37; Percentage of 
hospitals that responded to survey: 84.

State: Michigan; Number of hospitals that were sent surveys: 74; Number 
of hospitals that responded to survey: 53; Percentage of hospitals that 
responded to survey: 72.

State: Minnesota; Number of hospitals that were sent surveys: 33; 
Number of hospitals that responded to survey: 25; Percentage of 
hospitals that responded to survey: 76.

State: Mississippi; Number of hospitals that were sent surveys: 16; 
Number of hospitals that responded to survey: 12; Percentage of 
hospitals that responded to survey: 75.

State: Missouri; Number of hospitals that were sent surveys: 57; Number 
of hospitals that responded to survey: 37; Percentage of hospitals that 
responded to survey: 65.

State: Montana; Number of hospitals that were sent surveys: 3; Number 
of hospitals that responded to survey: 2; Percentage of hospitals that 
responded to survey: 67.

State: Nebraska; Number of hospitals that were sent surveys: 9; Number 
of hospitals that responded to survey: 8; Percentage of hospitals that 
responded to survey: 89.

State: Nevada; Number of hospitals that were sent surveys: 5; Number of 
hospitals that responded to survey: 4; Percentage of hospitals that 
responded to survey: 80.

State: New Hampshire; Number of hospitals that were sent surveys: 9; 
Number of hospitals that responded to survey: 7; Percentage of 
hospitals that responded to survey: 78.

State: New Jersey; Number of hospitals that were sent surveys: 60; 
Number of hospitals that responded to survey: 48; Percentage of 
hospitals that responded to survey: 80.

State: New Mexico; Number of hospitals that were sent surveys: 10; 
Number of hospitals that responded to survey: 6; Percentage of 
hospitals that responded to survey: 60.

State: New York; Number of hospitals that were sent surveys: 125; 
Number of hospitals that responded to survey: 94; Percentage of 
hospitals that responded to survey: 75.

State: North Carolina; Number of hospitals that were sent surveys: 39; 
Number of hospitals that responded to survey: 31; Percentage of 
hospitals that responded to survey: 79.

State: North Dakota; Number of hospitals that were sent surveys: 4; 
Number of hospitals that responded to survey: 3; Percentage of 
hospitals that responded to survey: 75.

State: Ohio; Number of hospitals that were sent surveys: 96; Number of 
hospitals that responded to survey: 71; Percentage of hospitals that 
responded to survey: 74.

State: Oklahoma; Number of hospitals that were sent surveys: 24; Number 
of hospitals that responded to survey: 16; Percentage of hospitals that 
responded to survey: 67.

State: Oregon; Number of hospitals that were sent surveys: 23; Number 
of hospitals that responded to survey: 19; Percentage of hospitals that 
responded to survey: 83.

State: Pennsylvania; Number of hospitals that were sent surveys: 117; 
Number of hospitals that responded to survey: 93; Percentage of 
hospitals that responded to survey: 79.

State: Rhode Island; Number of hospitals that were sent surveys: 9; 
Number of hospitals that responded to survey: 4; Percentage of 
hospitals that responded to survey: 44.

State: South Carolina; Number of hospitals that were sent surveys: 32; 
Number of hospitals that responded to survey: 24; Percentage of 
hospitals that responded to survey: 75.

State: South Dakota; Number of hospitals that were sent surveys: 5; 
Number of hospitals that responded to survey: 4; Percentage of 
hospitals that responded to survey: 80.

State: Tennessee; Number of hospitals that were sent surveys: 40; 
Number of hospitals that responded to survey: 36; Percentage of 
hospitals that responded to survey: 90.

State: Texas; Number of hospitals that were sent surveys: 189; Number 
of hospitals that responded to survey: 134; Percentage of hospitals 
that responded to survey: 71.

State: Utah; Number of hospitals that were sent surveys: 18; Number of 
hospitals that responded to survey: 14; Percentage of hospitals that 
responded to survey: 78.

State: Vermont; Number of hospitals that were sent surveys: 2; Number 
of hospitals that responded to survey: 2; Percentage of hospitals that 
responded to survey: 100.

State: Virginia; Number of hospitals that were sent surveys: 40; Number 
of hospitals that responded to survey: 33; Percentage of hospitals that 
responded to survey: 83.

State: Washington; Number of hospitals that were sent surveys: 33; 
Number of hospitals that responded to survey: 26; Percentage of 
hospitals that responded to survey: 79.

State: West Virginia; Number of hospitals that were sent surveys: 15; 
Number of hospitals that responded to survey: 11; Percentage of 
hospitals that responded to survey: 73.

State: Wisconsin; Number of hospitals that were sent surveys: 51; 
Number of hospitals that responded to survey: 41; Percentage of 
hospitals that responded to survey: 80.

State: Wyoming; Number of hospitals that were sent surveys: 2; Number 
of hospitals that responded to survey: 2; Percentage of hospitals that 
responded to survey: 100.

Source: GAO.

[End of table]

Table 5: Percentage of Urban Hospitals with a Written Emergency 
Response Plan Addressing Bioterrorism, by State:

State: Alabama; Percentage of hospitals: 80.9.

State: Arizona; Percentage of hospitals: 89.9.

State: Arkansas; Percentage of hospitals: 100.0.

State: California; Percentage of hospitals: 88.9.

State: Colorado; Percentage of hospitals: 89.2.

State: Connecticut; Percentage of hospitals: 85.7.

State: Florida; Percentage of hospitals: 90.4.

State: Georgia; Percentage of hospitals: 85.2.

State: Illinois; Percentage of hospitals: 81.4.

State: Indiana; Percentage of hospitals: 85.3.

State: Iowa; Percentage of hospitals: 76.9.

State: Kansas; Percentage of hospitals: 66.7.

State: Kentucky; Percentage of hospitals: 90.1.

State: Maryland; Percentage of hospitals: 80.8.

State: Massachusetts; Percentage of hospitals: 88.9.

State: Michigan; Percentage of hospitals: 78.0.

State: Minnesota; Percentage of hospitals: 68.0.

State: Mississippi; Percentage of hospitals: 91.8.

State: Missouri; Percentage of hospitals: 77.3.

State: New Jersey; Percentage of hospitals: 93.5.

State: New York; Percentage of hospitals: 74.1.

State: North Carolina; Percentage of hospitals: 80.0.

State: Ohio; Percentage of hospitals: 81.7.

State: Oklahoma; Percentage of hospitals: 79.6.

State: Oregon; Percentage of hospitals: 71.1.

State: Pennsylvania; Percentage of hospitals: 77.0.

State: South Carolina; Percentage of hospitals: 83.3.

State: Tennessee; Percentage of hospitals: 83.2.

State: Texas; Percentage of hospitals: 74.2.

State: Utah; Percentage of hospitals: 93.5.

State: Virginia; Percentage of hospitals: 73.8.

State: Washington; Percentage of hospitals: 84.8.

State: West Virginia; Percentage of hospitals: 63.0.

State: Wisconsin; Percentage of hospitals: 78.0.

Source: GAO.

Note: Responses were weighted to provide estimates for the universe of 
hospitals. Data are presented for states that had at least 10 hospitals 
respond to survey and a response rate of at least 50 percent.

[End of table]

Table 6: Percentage of Urban Hospitals That Reported Specifying in 
Emergency Response Plan to Contact the Specified Entities during an 
Emergency, by State:

State: Alabama; Law enforcement: 94.5; Fire: 89.0; EMS: 89.0; HAZMAT: 
89.0; Other hospitals: 89.0; Public health agencies: 81.9; Other state 
and local government agencies: 94.5; Other laboratories: 48.8; Public 
private utilities: 63.3.

State: Arizona; Law enforcement: 100.0; Fire: 100.0; EMS: 94.4; HAZMAT: 
81.6; Other hospitals: 94.4; Public health agencies: 94.4; Other state 
and local government agencies: 83.2; Other laboratories: 74.1; Public 
private utilities: 81.6.

State: Arkansas; Law enforcement: 93.7; Fire: 93.7; EMS: 93.7; HAZMAT: 
87.4; Other hospitals: 93.7; Public health agencies: 93.7; Other state 
and local government agencies: 87.4; Other laboratories: 40.4; Public 
private utilities: 85.6.

State: California; Law enforcement: 94.1; Fire: 92.9; EMS: 96.4; 
HAZMAT: 89.9; Other hospitals: 86.3; Public health agencies: 97.2; 
Other state and local government agencies: 85.8; Other laboratories: 
45.8; Public private utilities: 70.0.

State: Colorado; Law enforcement: 93.5; Fire: 94.0; EMS: 68.1; HAZMAT: 
94.0; Other hospitals: 87.9; Public health agencies: 100.0; Other state 
and local government agencies: 94.0; Other laboratories: 45.8; Public 
private utilities: 80.4.

State: Connecticut; Law enforcement: 100.0; Fire: 100.0; EMS: 100.0; 
HAZMAT: 100.0; Other hospitals: 100.0; Public health agencies: 94.4; 
Other state and local government agencies: 77.8; Other laboratories: 
70.6; Public private utilities: 83.3.

State: Florida; Law enforcement: 95.9; Fire: 97.3; EMS: 94.7; HAZMAT: 
95.9; Other hospitals: 91.4; Public health agencies: 93.9; Other state 
and local government agencies: 97.0; Other laboratories: 58.8; Public 
private utilities: 73.0.

State: Georgia; Law enforcement: 93.7; Fire: 100.0; EMS: 96.5; HAZMAT: 
94.5; Other hospitals: 89.8; Public health agencies: 90.9; Other state 
and local government agencies: 93.5; Other laboratories: 64.1; Public 
private utilities: 78.6.

State: Illinois; Law enforcement: 92.5; Fire: 88.1; EMS: 92.6; HAZMAT: 
84.6; Other hospitals: 94.1; Public health agencies: 94.1; Other state 
and local government agencies: 78.8; Other laboratories: 58.5; Public 
private utilities: 66.2.

State: Indiana; Law enforcement: 91.4; Fire: 94.3; EMS: 94.3; HAZMAT: 
91.1; Other hospitals: 91.4; Public health agencies: 94.3; Other state 
and local government agencies: 91.1; Other laboratories: 60.2; Public 
private utilities: 79.9.

State: Iowa; Law enforcement: 90.0; Fire: 90.0; EMS: 90.0; HAZMAT: 
90.0; Other hospitals: 90.0; Public health agencies: 80.0; Other state 
and local government agencies: 80.0; Other laboratories: 80.0; Public 
private utilities: 100.0.

State: Kansas; Law enforcement: 100.0; Fire: 100.0; EMS: 100.0; HAZMAT: 
100.0; Other hospitals: 87.5; Public health agencies: 100.0; Other 
state and local government agencies: 100.0; Other laboratories: 62.5; 
Public private utilities: 87.5.

State: Kentucky; Law enforcement: 89.1; Fire: 83.6; EMS: 83.6; HAZMAT: 
76.6; Other hospitals: 83.6; Public health agencies: 89.1; Other state 
and local government agencies: 100.0; Other laboratories: 61.7; Public 
private utilities: 67.2.

State: Maryland; Law enforcement: 100.0; Fire: 95.2; EMS: 100.0; 
HAZMAT: 90.5; Other hospitals: 81.0; Public health agencies: 100.0; 
Other state and local government agencies: 95.2; Other laboratories: 
57.1; Public private utilities: 85.0.

State: Massachusetts; Law enforcement: 100.0; Fire: 96.8; EMS: 96.8; 
HAZMAT: 96.8; Other hospitals: 77.4; Public health agencies: 100.0; 
Other state and local government agencies: 93.3; Other laboratories: 
71.0; Public private utilities: 80.6.

State: Michigan; Law enforcement: 92.1; Fire: 100.0; EMS: 88.9; HAZMAT: 
89.5; Other hospitals: 92.1; Public health agencies: 97.4; Other state 
and local government agencies: 92.3; Other laboratories: 62.2; Public 
private utilities: 81.6.

State: Minnesota; Law enforcement: 100.0; Fire: 100.0; EMS: 100.0; 
HAZMAT: 94.1; Other hospitals: 94.1; Public health agencies: 94.1; 
Other state and local government agencies: 76.5; Other laboratories: 
41.2; Public private utilities: 56.3.

State: Mississippi; Law enforcement: 91.0; Fire: 91.0; EMS: 100.0; 
HAZMAT: 70.5; Other hospitals: 100.0; Public health agencies: 100.0; 
Other state and local government agencies: 100.0; Other laboratories: 
67.6; Public private utilities: 70.5.

State: Missouri; Law enforcement: 82.3; Fire: 89.4; EMS: 88.4; HAZMAT: 
81.3; Other hospitals: 84.3; Public health agencies: 88.4; Other state 
and local government agencies: 81.3; Other laboratories: 46.0; Public 
private utilities: 70.7.

State: New Jersey; Law enforcement: 97.7; Fire: 95.3; EMS: 95.3; 
HAZMAT: 95.3; Other hospitals: 90.7; Public health agencies: 88.1; 
Other state and local government agencies: 90.7; Other laboratories: 
61.9; Public private utilities: 86.0.

State: New York; Law enforcement: 100.0; Fire: 100.0; EMS: 95.1; 
HAZMAT: 91.8; Other hospitals: 86.1; Public health agencies: 98.5; 
Other state and local government agencies: 95.6; Other laboratories: 
58.9; Public private utilities: 70.1.

State: North Carolina; Law enforcement: 95.8; Fire: 95.8; EMS: 91.7; 
HAZMAT: 83.3; Other hospitals: 87.5; Public health agencies: 87.0; 
Other state and local government agencies: 91.7; Other laboratories: 
47.6; Public private utilities: 82.6.

State: Ohio; Law enforcement: 96.4; Fire: 92.7; EMS: 94.5; HAZMAT: 
90.9; Other hospitals: 94.4; Public health agencies: 94.5; Other state 
and local government agencies: 92.7; Other laboratories: 57.7; Public 
private utilities: 81.5.

State: Oklahoma; Law enforcement: 92.2; Fire: 92.2; EMS: 92.2; HAZMAT: 
92.2; Other hospitals: 100.0; Public health agencies: 100.0; Other 
state and local government agencies: 92.2; Other laboratories: 81.6; 
Public private utilities: 92.2.

State: Oregon; Law enforcement: 75.6; Fire: 75.6; EMS: 75.6; HAZMAT: 
100.0; Other hospitals: 67.4; Public health agencies: 100.0; Other 
state and local government agencies: 67.4; Other laboratories: 34.9; 
Public private utilities: 59.3.

State: Pennsylvania; Law enforcement: 92.7; Fire: 97.1; EMS: 95.7; 
HAZMAT: 95.7; Other hospitals: 86.8; Public health agencies: 95.6; 
Other state and local government agencies: 95.7; Other laboratories: 
58.0; Public private utilities: 80.0.

State: South Carolina; Law enforcement: 100.0; Fire: 93.0; EMS: 100.0; 
HAZMAT: 93.0; Other hospitals: 100.0; Public health agencies: 93.9; 
Other state and local government agencies: 100.0; Other laboratories: 
38.3; Public private utilities: 87.8.

State: Tennessee; Law enforcement: 100.0; Fire: 90.4; EMS: 93.6; 
HAZMAT: 89.5; Other hospitals: 90.4; Public health agencies: 100.0; 
Other state and local government agencies: 96.8; Other laboratories: 
75.7; Public private utilities: 74.9.

State: Texas; Law enforcement: 90.0; Fire: 90.4; EMS: 90.3; HAZMAT: 
88.3; Other hospitals: 80.3; Public health agencies: 90.6; Other state 
and local government agencies: 86.8; Other laboratories: 56.2; Public 
private utilities: 76.3.

State: Utah; Law enforcement: 100.0; Fire: 100.0; EMS: 91.1; HAZMAT: 
100.0; Other hospitals: 93.1; Public health agencies: 100.0; Other 
state and local government agencies: 84.2; Other laboratories: 34.0; 
Public private utilities: 84.2.

State: Virginia; Law enforcement: 96.1; Fire: 92.1; EMS: 100.0; HAZMAT: 
88.2; Other hospitals: 100.0; Public health agencies: 95.9; Other state 
and local government agencies: 92.1; Other laboratories: 64.9; Public 
private utilities: 81.3.

State: Washington; Law enforcement: 91.0; Fire: 91.0; EMS: 86.5; 
HAZMAT: 86.5; Other hospitals: 95.3; Public health agencies: 100.0; 
Other state and local government agencies: 85.9; Other laboratories: 
53.3; Public private utilities: 53.3.

State: West Virginia; Law enforcement: 100.0; Fire: 100.0; EMS: 100.0; 
HAZMAT: 100.0; Other hospitals: 100.0; Public health agencies: 86.3; 
Other state and local government agencies: 100.0; Other laboratories: 
63.7; Public private utilities: 54.9.

State: Wisconsin; Law enforcement: 96.8; Fire: 96.8; EMS: 90.3; HAZMAT: 
93.5; Other hospitals: 87.5; Public health agencies: 90.0; Other state 
and local government agencies: 90.6; Other laboratories: 45.2; Public 
private utilities: 65.6.

Source: GAO.

Note: Responses were weighted to provide estimates for the universe of 
hospitals. Data are presented for states that had at least 10 hospitals 
respond to survey and a response rate of at least 50 percent.

[End of table]

Table 7: Percentage of Urban Hospitals Whose Mass Casualty Plans 
Address Bioterrorism and Describe How to Manage the Specified Function, 
by State:

State: Alabama; Decontamination of victims: 100.0; Mass patient: 94.5; 
Worried well: 76.3; Mass fatality: 68.5; Mass evacuation: 92.9; 
Obtaining additional pharmaceuticals: 94.2; Obtaining additional staff 
for surge capacity: 100.0; Obtaining additional other supplies for 
surge capacity: 94.5; Hospital security: 100.0.

State: Arizona; Decontamination of victims: 88.8; Mass patient: 100.0; 
Worried well: 69.3; Mass fatality: 76.0; Mass evacuation: 92.4; 
Obtaining additional pharmaceuticals: 92.4; Obtaining additional staff 
for surge capacity: 100.0; Obtaining additional other supplies for 
surge capacity: 84.8; Hospital security: 92.4.

State: Arkansas; Decontamination of victims: 87.4; Mass patient: 93.7; 
Worried well: 85.6; Mass fatality: 66.7; Mass evacuation: 93.3; 
Obtaining additional pharmaceuticals: 93.7; Obtaining additional staff 
for surge capacity: 100.0; Obtaining additional other supplies for 
surge capacity: 93.7; Hospital security: 100.0.

State: California; Decontamination of victims: 94.7; Mass patient: 
95.5; Worried well: 82.9; Mass fatality: 75.3; Mass evacuation: 95.6; 
Obtaining additional pharmaceuticals: 91.1; Obtaining additional staff 
for surge capacity: 97.9; Obtaining additional other supplies for surge 
capacity: 97.8; Hospital security: 98.9.

State: Colorado; Decontamination of victims: 100.0; Mass patient: 
100.0; Worried well: 81.9; Mass fatality: 86.2; Mass evacuation: 87.9; 
Obtaining additional pharmaceuticals: 94.0; Obtaining additional staff 
for surge capacity: 91.8; Obtaining additional other supplies for surge 
capacity: 100.0; Hospital security: 100.0.

State: Connecticut; Decontamination of victims: 100.0; Mass patient: 
100.0; Worried well: 88.9; Mass fatality: 66.7; Mass evacuation: 100.0; 
Obtaining additional pharmaceuticals: 88.9; Obtaining additional staff 
for surge capacity: 94.4; Obtaining additional other supplies for surge 
capacity: 94.4; Hospital security: 100.0.

State: Florida; Decontamination of victims: 95.0; Mass patient: 95.5; 
Worried well: 69.7; Mass fatality: 77.6; Mass evacuation: 88.9; 
Obtaining additional pharmaceuticals: 98.5; Obtaining additional staff 
for surge capacity: 98.8; Obtaining additional other supplies for surge 
capacity: 100.0; Hospital security: 100.0.

State: Georgia; Decontamination of victims: 94.5; Mass patient: 97.2; 
Worried well: 84.2; Mass fatality: 79.9; Mass evacuation: 86.9; 
Obtaining additional pharmaceuticals: 86.2; Obtaining additional staff 
for surge capacity: 93.7; Obtaining additional other supplies for surge 
capacity: 91.5; Hospital security: 96.5.

State: Illinois; Decontamination of victims: 97.0; Mass patient: 98.5; 
Worried well: 77.6; Mass fatality: 77.3; Mass evacuation: 91.0; 
Obtaining additional pharmaceuticals: 97.0; Obtaining additional staff 
for surge capacity: 97.0; Obtaining additional other supplies for surge 
capacity: 97.0; Hospital security: 100.0.

State: Indiana; Decontamination of victims: 94.1; Mass patient: 94.3; 
Worried well: 78.5; Mass fatality: 79.9; Mass evacuation: 85.7; 
Obtaining additional pharmaceuticals: 77.0; Obtaining additional staff 
for surge capacity: 97.1; Obtaining additional other supplies for surge 
capacity: 94.3; Hospital security: 94.3.

State: Iowa; Decontamination of victims: 100.0; Mass patient: 100.0; 
Worried well: 80.0; Mass fatality: 100.0; Mass evacuation: 90.0; 
Obtaining additional pharmaceuticals: 100.0; Obtaining additional 
staff for surge capacity: 100.0; Obtaining additional other supplies 
for surge capacity: 100.0; Hospital security: 100.0.

State: Kansas; Decontamination of victims: 100.0; Mass patient: 87.5; 
Worried well: 71.4; Mass fatality: 75.0; Mass evacuation: 100.0; 
Obtaining additional pharmaceuticals: 87.5; Obtaining additional staff 
for surge capacity: 87.5; Obtaining additional other supplies for surge 
capacity: 87.5; Hospital security: 100.0.

State: Kentucky; Decontamination of victims: 89.1; Mass patient: 100.0; 
Worried well: 83.6; Mass fatality: 100.0; Mass evacuation: 94.5; 
Obtaining additional pharmaceuticals: 100.0; Obtaining additional 
staff for surge capacity: 100.0; Obtaining additional other supplies 
for surge capacity: 94.5; Hospital security: 100.0.

State: Maryland; Decontamination of victims: 100.0; Mass patient: 
100.0; Worried well: 95.0; Mass fatality: 95.0; Mass evacuation: 94.4; 
Obtaining additional pharmaceuticals: 100.0; Obtaining additional 
staff for surge capacity: 100.0; Obtaining additional other supplies 
for surge capacity: 100.0; Hospital security: 100.0.

State: Massachusetts; Decontamination of victims: 96.9; Mass patient: 
93.8; Worried well: 77.4; Mass fatality: 75.0; Mass evacuation: 87.5; 
Obtaining additional pharmaceuticals: 81.3; Obtaining additional staff 
for surge capacity: 100.0; Obtaining additional other supplies for 
surge capacity: 87.5; Hospital security: 100.0.

State: Michigan; Decontamination of victims: 92.3; Mass patient: 94.9; 
Worried well: 66.7; Mass fatality: 65.8; Mass evacuation: 87.2; 
Obtaining additional pharmaceuticals: 73.7; Obtaining additional staff 
for surge capacity: 92.3; Obtaining additional other supplies for surge 
capacity: 89.7; Hospital security: 94.9.

State: Minnesota; Decontamination of victims: 76.5; Mass patient: 88.2; 
Worried well: 52.9; Mass fatality: 52.9; Mass evacuation: 64.7; 
Obtaining additional pharmaceuticals: 94.1; Obtaining additional staff 
for surge capacity: 100.0; Obtaining additional other supplies for 
surge capacity: 94.1; Hospital security: 100.0.

State: Mississippi; Decontamination of victims: 79.5; Mass patient: 
100.0; Worried well: 79.5; Mass fatality: 82.0; Mass evacuation: 91.0; 
Obtaining additional pharmaceuticals: 100.0; Obtaining additional 
staff for surge capacity: 91.0; Obtaining additional other supplies for 
surge capacity: 91.0; Hospital security: 91.0.

State: Missouri; Decontamination of victims: 96.5; Mass patient: 96.5; 
Worried well: 80.6; Mass fatality: 78.8; Mass evacuation: 89.4; 
Obtaining additional pharmaceuticals: 82.3; Obtaining additional staff 
for surge capacity: 96.5; Obtaining additional other supplies for surge 
capacity: 82.3; Hospital security: 96.5.

State: New Jersey; Decontamination of victims: 100.0; Mass patient: 
93.0; Worried well: 65.9; Mass fatality: 75.0; Mass evacuation: 90.7; 
Obtaining additional pharmaceuticals: 97.7; Obtaining additional staff 
for surge capacity: 93.0; Obtaining additional other supplies for surge 
capacity: 95.3; Hospital security: 100.0.

State: New York; Decontamination of victims: 91.1; Mass patient: 98.5; 
Worried well: 77.1; Mass fatality: 65.4; Mass evacuation: 92.4; 
Obtaining additional pharmaceuticals: 80.2; Obtaining additional staff 
for surge capacity: 97.0; Obtaining additional other supplies for surge 
capacity: 92.2; Hospital security: 98.5.

State: North Carolina; Decontamination of victims: 95.8; Mass patient: 
87.5; Worried well: 62.5; Mass fatality: 58.3; Mass evacuation: 79.2; 
Obtaining additional pharmaceuticals: 72.7; Obtaining additional staff 
for surge capacity: 91.7; Obtaining additional other supplies for surge 
capacity: 75.0; Hospital security: 95.8.

State: Ohio; Decontamination of victims: 100.0; Mass patient: 96.4; 
Worried well: 75.9; Mass fatality: 81.8; Mass evacuation: 94.4; 
Obtaining additional pharmaceuticals: 83.6; Obtaining additional staff 
for surge capacity: 96.4; Obtaining additional other supplies for surge 
capacity: 92.7; Hospital security: 98.2.

State: Oklahoma; Decontamination of victims: 100.0; Mass patient: 
100.0; Worried well: 90.8; Mass fatality: 91.6; Mass evacuation: 88.9; 
Obtaining additional pharmaceuticals: 91.6; Obtaining additional staff 
for surge capacity: 100.0; Obtaining additional other supplies for 
surge capacity: 100.0; Hospital security: 100.0.

State: Oregon; Decontamination of victims: 100.0; Mass patient: 100.0; 
Worried well: 100.0; Mass fatality: 91.9; Mass evacuation: 100.0; 
Obtaining additional pharmaceuticals: 91.9; Obtaining additional staff 
for surge capacity: 83.7; Obtaining additional other supplies for surge 
capacity: 91.9; Hospital security: 100.0.

State: Pennsylvania; Decontamination of victims: 94.2; Mass patient: 
94.3; Worried well: 71.8; Mass fatality: 59.3; Mass evacuation: 90.0; 
Obtaining additional pharmaceuticals: 82.3; Obtaining additional staff 
for surge capacity: 95.7; Obtaining additional other supplies for surge 
capacity: 92.9; Hospital security: 100.0.

State: South Carolina; Decontamination of victims: 100.0; Mass patient: 
100.0; Worried well: 78.7; Mass fatality: 90.7; Mass evacuation: 95.3; 
Obtaining additional pharmaceuticals: 100.0; Obtaining additional 
staff for surge capacity: 100.0; Obtaining additional other supplies 
for surge capacity: 100.0; Hospital security: 100.0.

State: Tennessee; Decontamination of victims: 93.6; Mass patient: 96.8; 
Worried well: 79.8; Mass fatality: 86.2; Mass evacuation: 96.8; 
Obtaining additional pharmaceuticals: 90.4; Obtaining additional staff 
for surge capacity: 93.6; Obtaining additional other supplies for surge 
capacity: 93.6; Hospital security: 92.7.

State: Texas; Decontamination of victims: 89.8; Mass patient: 98.1; 
Worried well: 74.8; Mass fatality: 77.4; Mass evacuation: 88.1; 
Obtaining additional pharmaceuticals: 74.5; Obtaining additional staff 
for surge capacity: 91.2; Obtaining additional other supplies for surge 
capacity: 86.9; Hospital security: 97.1.

State: Utah; Decontamination of victims: 100.0; Mass patient: 100.0; 
Worried well: 100.0; Mass fatality: 100.0; Mass evacuation: 100.0; 
Obtaining additional pharmaceuticals: 77.2; Obtaining additional staff 
for surge capacity: 93.1; Obtaining additional other supplies for surge 
capacity: 91.1; Hospital security: 100.0.

State: Virginia; Decontamination of victims: 91.0; Mass patient: 91.0; 
Worried well: 82.0; Mass fatality: 75.3; Mass evacuation: 91.0; 
Obtaining additional pharmaceuticals: 87.1; Obtaining additional staff 
for surge capacity: 96.1; Obtaining additional other supplies for surge 
capacity: 95.0; Hospital security: 95.0.

State: Washington; Decontamination of victims: 100.0; Mass patient: 
86.5; Worried well: 73.1; Mass fatality: 73.1; Mass evacuation: 91.0; 
Obtaining additional pharmaceuticals: 86.5; Obtaining additional staff 
for surge capacity: 100.0; Obtaining additional other supplies for 
surge capacity: 86.5; Hospital security: 100.0.

State: West Virginia; Decontamination of victims: 100.0; Mass patient: 
100.0; Worried well: 68.7; Mass fatality: 86.3; Mass evacuation: 86.3; 
Obtaining additional pharmaceuticals: 86.3; Obtaining additional staff 
for surge capacity: 100.0; Obtaining additional other supplies for 
surge capacity: 86.3; Hospital security: 100.0.

State: Wisconsin; Decontamination of victims: 100.0; Mass patient: 
96.9; Worried well: 70.0; Mass fatality: 84.4; Mass evacuation: 93.8; 
Obtaining additional pharmaceuticals: 75.0; Obtaining additional staff 
for surge capacity: 93.8; Obtaining additional other supplies for surge 
capacity: 87.5; Hospital security: 100.0.

Source: GAO.

Note: Responses were weighted to provide estimates for the universe of 
hospitals. Data are presented for states that had at least 10 hospitals 
respond to survey and a response rate of at least 50 percent.

[End of table]

Table 8: Percentage of Urban Hospitals That Had Agreements with Other 
Hospitals or City, County, State, and Regional Organizations to Provide 
or Share Resources in the Event of Bioterrorism, by State:

State: Alabama; Hospitals: 73.1; City: 51.1; County: 45.5; State: 35.7; 
Regional: 30.8.

State: Arizona; Hospitals: 73.1; City: 52.8; County: 58.5; State: 21.1; 
Regional: 21.1.

State: Arkansas; Hospitals: 75.6; City: 70.8; County: 52.7; State: 
48.6; Regional: 35.4.

State: California; Hospitals: 55.5; City: 36.8; County: 58.9; State: 
33.6; Regional: 32.2.

State: Colorado; Hospitals: 74.4; City: 43.8; County: 38.3; State: 
21.9; Regional: 32.8.

State: Connecticut; Hospitals: 45.0; City: 57.9; County: 14.3; State: 
33.3; Regional: 35.3.

State: Florida; Hospitals: 75.8; City: 49.8; County: 64.5; State: 39.3; 
Regional: 34.7.

State: Georgia; Hospitals: 76.3; City: 55.1; County: 62.6; State: 38.4; 
Regional: 42.9.

State: Illinois; Hospitals: 61.0; City: 55.2; County: 45.6; State: 
55.6; Regional: 49.3.

State: Indiana; Hospitals: 70.8; City: 60.5; County: 68.5; State: 41.5; 
Regional: 34.4.

State: Iowa; Hospitals: 84.6; City: 72.7; County: 72.7; State: 50.0; 
Regional: 40.0.

State: Kansas; Hospitals: 58.3; City: 44.4; County: 54.5; State: 33.3; 
Regional: 40.0.

State: Kentucky; Hospitals: 76.5; City: 58.5; County: 67.2; State: 
14.0; Regional: 34.7.

State: Maryland; Hospitals: 52.4; City: 33.3; County: 66.7; State: 
43.8; Regional: 43.8.

State: Massachusetts; Hospitals: 50.0; City: 57.1; County: 21.9; State: 
34.4; Regional: 45.5.

State: Michigan; Hospitals: 73.6; City: 53.1; County: 70.0; State: 
40.0; Regional: 57.4.

State: Minnesota; Hospitals: 72.7; City: 42.9; County: 47.6; State: 
35.0; Regional: 35.0.

State: Mississippi; Hospitals: 84.8; City: 48.2; County: 48.2; State: 
45.9; Regional: 48.2.

State: Missouri; Hospitals: 70.7; City: 54.2; County: 39.6; State: 
27.7; Regional: 39.6.

State: New Jersey; Hospitals: 73.3; City: 42.9; County: 59.5; State: 
38.5; Regional: 31.6.

State: New York; Hospitals: 58.7; City: 27.6; County: 44.3; State: 
21.1; Regional: 20.8.

State: North Carolina; Hospitals: 64.5; City: 35.5; County: 45.2; 
State: 33.3; Regional: 43.3.

State: Ohio; Hospitals: 82.4; City: 68.3; County: 71.3; State: 45.8; 
Regional: 46.6.

State: Oklahoma; Hospitals: 92.0; City: 83.5; County: 83.5; State: 
69.1; Regional: 64.5.

State: Oregon; Hospitals: 88.2; City: 65.6; County: 57.9; State: 18.4; 
Regional: 40.5.

State: Pennsylvania; Hospitals: 60.6; City: 39.2; County: 52.1; State: 
26.1; Regional: 41.5.

State: South Carolina; Hospitals: 91.1; City: 69.6; County: 81.6; 
State: 69.7; Regional: 41.0.

State: Tennessee; Hospitals: 82.5; City: 72.8; County: 72.8; State: 
58.7; Regional: 39.5.

State: Texas; Hospitals: 57.2; City: 40.5; County: 31.5; State: 17.1; 
Regional: 24.2.

State: Utah; Hospitals: 82.6; City: 45.9; County: 45.9; State: 50.0; 
Regional: 53.6.

State: Virginia; Hospitals: 93.8; City: 59.2; County: 59.2; State: 
50.3; Regional: 84.6.

State: Washington; Hospitals: 92.4; City: 73.1; County: 76.5; State: 
50.7; Regional: 43.6.

State: West Virginia; Hospitals: 91.4; City: 71.6; County: 65.4; State: 
45.7; Regional: 25.9.

State: Wisconsin; Hospitals: 62.2; City: 44.4; County: 48.6; State: 
16.7; Regional: 24.1.

Source: GAO.

Note: Responses were weighted to provide estimates for the universe of 
hospitals. Data are presented for states that had at least 10 hospitals 
respond to survey and a response rate of at least 50 percent.

[End of table]

Table 9: Percentage of Urban Hospitals That Have Provided Training to 
Staff (Services, Courses, or Self-Learning Materials) to Identify and 
Diagnose Symptoms for the Following Biological Agents, by State:

State: Alabama; Smallpox: 88.2; Anthrax: 92.1; Plague: 79.2; Botulism: 
71.3; Tularemia: 62.4; Hemorrhagic fever viruses: 71.3.

State: Arizona; Smallpox: 73.4; Anthrax: 78.4; Plague: 73.4; Botulism: 
73.4; Tularemia: 68.3; Hemorrhagic fever viruses: 73.4.

State: Arkansas; Smallpox: 93.7; Anthrax: 93.7; Plague: 79.3; Botulism: 
87.4; Tularemia: 79.3; Hemorrhagic fever viruses: 73.0.

State: California; Smallpox: 89.2; Anthrax: 91.0; Plague: 87.4; 
Botulism: 86.5; Tularemia: 82.8; Hemorrhagic fever viruses: 84.6.

State: Colorado; Smallpox: 84.7; Anthrax: 89.8; Plague: 79.6; Botulism: 
73.0; Tularemia: 67.9; Hemorrhagic fever viruses: 73.0.

State: Connecticut; Smallpox: 85.7; Anthrax: 95.2; Plague: 81.0; 
Botulism: 85.0; Tularemia: 80.0; Hemorrhagic fever viruses: 70.0.

State: Florida; Smallpox: 86.2; Anthrax: 94.3; Plague: 74.2; Botulism: 
78.2; Tularemia: 65.7; Hemorrhagic fever viruses: 69.1.

State: Georgia; Smallpox: 88.5; Anthrax: 100.0; Plague: 88.5; Botulism: 
88.5; Tularemia: 86.2; Hemorrhagic fever viruses: 83.2.

State: Illinois; Smallpox: 95.2; Anthrax: 96.4; Plague: 78.5; Botulism: 
83.7; Tularemia: 72.7; Hemorrhagic fever viruses: 73.4.

State: Indiana; Smallpox: 81.6; Anthrax: 89.8; Plague: 76.7; Botulism: 
74.3; Tularemia: 63.9; Hemorrhagic fever viruses: 62.2.

State: Iowa; Smallpox: 92.3; Anthrax: 92.3; Plague: 76.9; Botulism: 
84.6; Tularemia: 66.7; Hemorrhagic fever viruses: 83.3.

State: Kansas; Smallpox: 83.3; Anthrax: 91.7; Plague: 66.7; Botulism: 
66.7; Tularemia: 66.7; Hemorrhagic fever viruses: 58.3.

State: Kentucky; Smallpox: 90.1; Anthrax: 100.0; Plague: 90.1; 
Botulism: 90.1; Tularemia: 85.2; Hemorrhagic fever viruses: 80.3.

State: Maryland; Smallpox: 88.5; Anthrax: 96.2; Plague: 84.6; Botulism: 
84.6; Tularemia: 84.0; Hemorrhagic fever viruses: 80.0.

State: Massachusetts; Smallpox: 89.2; Anthrax: 91.9; Plague: 77.1; 
Botulism: 75.0; Tularemia: 75.0; Hemorrhagic fever viruses: 71.4.

State: Michigan; Smallpox: 88.7; Anthrax: 92.5; Plague: 81.1; Botulism: 
79.2; Tularemia: 64.7; Hemorrhagic fever viruses: 65.4.

State: Minnesota; Smallpox: 91.7; Anthrax: 91.7; Plague: 82.6; 
Botulism: 87.0; Tularemia: 65.2; Hemorrhagic fever viruses: 59.1.

State: Mississippi; Smallpox: 92.4; Anthrax: 92.4; Plague: 92.4; 
Botulism: 92.4; Tularemia: 92.4; Hemorrhagic fever viruses: 82.6.

State: Missouri; Smallpox: 83.3; Anthrax: 91.3; Plague: 70.0; Botulism: 
70.0; Tularemia: 70.0; Hemorrhagic fever viruses: 67.3.

State: New Jersey; Smallpox: 97.8; Anthrax: 100.0; Plague: 95.6; 
Botulism: 95.5; Tularemia: 86.4; Hemorrhagic fever viruses: 86.4.

State: New York; Smallpox: 89.3; Anthrax: 94.6; Plague: 87.8; Botulism: 
85.0; Tularemia: 76.3; Hemorrhagic fever viruses: 77.9.

State: North Carolina; Smallpox: 87.1; Anthrax: 93.5; Plague: 77.4; 
Botulism: 77.4; Tularemia: 64.5; Hemorrhagic fever viruses: 58.1.

State: Ohio; Smallpox: 88.8; Anthrax: 91.6; Plague: 84.6; Botulism: 
77.6; Tularemia: 65.9; Hemorrhagic fever viruses: 67.3.

State: Oklahoma; Smallpox: 87.6; Anthrax: 93.8; Plague: 87.6; Botulism: 
87.6; Tularemia: 76.8; Hemorrhagic fever viruses: 78.3.

State: Oregon; Smallpox: 94.2; Anthrax: 94.5; Plague: 76.9; Botulism: 
82.6; Tularemia: 69.4; Hemorrhagic fever viruses: 63.6.

State: Pennsylvania; Smallpox: 87.0; Anthrax: 91.3; Plague: 82.3; 
Botulism: 82.3; Tularemia: 74.2; Hemorrhagic fever viruses: 72.5.

State: South Carolina; Smallpox: 96.1; Anthrax: 96.1; Plague: 76.0; 
Botulism: 76.0; Tularemia: 52.5; Hemorrhagic fever viruses: 42.7.

State: Tennessee; Smallpox: 91.0; Anthrax: 93.7; Plague: 85.5; 
Botulism: 82.0; Tularemia: 78.6; Hemorrhagic fever viruses: 78.6.

State: Texas; Smallpox: 83.1; Anthrax: 92.5; Plague: 75.9; Botulism: 
77.0; Tularemia: 64.6; Hemorrhagic fever viruses: 62.5.

State: Utah; Smallpox: 85.2; Anthrax: 100.0; Plague: 85.2; Botulism: 
85.2; Tularemia: 85.2; Hemorrhagic fever viruses: 85.2.

State: Virginia; Smallpox: 85.5; Anthrax: 85.5; Plague: 85.0; Botulism: 
78.2; Tularemia: 64.1; Hemorrhagic fever viruses: 60.0.

State: Washington; Smallpox: 84.8; Anthrax: 92.4; Plague: 77.2; 
Botulism: 77.2; Tularemia: 65.8; Hemorrhagic fever viruses: 69.6.

State: West Virginia; Smallpox: 90.5; Anthrax: 100.0; Plague: 90.5; 
Botulism: 78.4; Tularemia: 78.4; Hemorrhagic fever viruses: 68.9.

State: Wisconsin; Smallpox: 92.5; Anthrax: 95.0; Plague: 82.5; 
Botulism: 87.5; Tularemia: 72.5; Hemorrhagic fever viruses: 72.5.

Source: GAO.

Note: Responses were weighted to provide estimates for the universe of 
hospitals. Data are presented for states that had at least 10 hospitals 
respond to survey and a response rate of at least 50 percent.

[End of table]

Table 10: Percentage of Urban Hospitals That Participated in Mass 
Casualty Drills Related to Biological Incidents by State:

State: Alabama; Percentage of hospitals: 54.5.

State: Arizona; Percentage of hospitals: 36.7.

State: Arkansas; Percentage of hospitals: 41.4.

State: California; Percentage of hospitals: 57.3.

State: Colorado; Percentage of hospitals: 35.8.

State: Connecticut; Percentage of hospitals: 47.6.

State: Florida; Percentage of hospitals: 58.4.

State: Georgia; Percentage of hospitals: 44.6.

State: Illinois; Percentage of hospitals: 38.3.

State: Indiana; Percentage of hospitals: 61.6.

State: Iowa; Percentage of hospitals: 53.8.

State: Kansas; Percentage of hospitals: 41.7.

State: Kentucky; Percentage of hospitals: 57.7.

State: Maryland; Percentage of hospitals: 38.5.

State: Massachusetts; Percentage of hospitals: 35.1.

State: Michigan; Percentage of hospitals: 43.4.

State: Minnesota; Percentage of hospitals: 32.0.

State: Mississippi; Percentage of hospitals: 65.2.

State: Missouri; Percentage of hospitals: 39.9.

State: New Jersey; Percentage of hospitals: 50.0.

State: New York; Percentage of hospitals: 33.6.

State: North Carolina; Percentage of hospitals: 45.2.

State: Ohio; Percentage of hospitals: 66.3.

State: Oklahoma; Percentage of hospitals: 51.7.

State: Oregon; Percentage of hospitals: 48.1.

State: Pennsylvania; Percentage of hospitals: 39.7.

State: South Carolina; Percentage of hospitals: 33.3.

State: Tennessee; Percentage of hospitals: 40.1.

State: Texas; Percentage of hospitals: 44.2.

State: Utah; Percentage of hospitals: 60.2.

State: Virginia; Percentage of hospitals: 70.9.

State: Washington; Percentage of hospitals: 54.3.

State: West Virginia; Percentage of hospitals: 17.3.

State: Wisconsin; Percentage of hospitals: 48.8.

Source: GAO.

Note: Responses were weighted to provide estimates for the universe of 
hospitals. Data are presented for states that had at least 10 hospitals 
respond to survey and a response rate of at least 50 percent.

[End of table]

[End of section]

Appendix II: Scope and Methodology:

Between May and September 2002 we surveyed more than 2,000 short-
term,[Footnote 26] nonfederal, general medical and surgical hospitals 
with emergency departments located in metropolitan statistical areas 
(MSAs).[Footnote 27] Survey hospitals were located in the 50 states and 
the District of Columbia.

The survey questionnaire contained three parts. The first and second 
parts addressed emergency room functioning, and the third part 
addressed hospital preparedness for bioterrorism. We reported our 
survey findings on emergency room functioning in March 2003.[Footnote 
28] We conducted our work between May 2002 and July 2003 in accordance 
with generally accepted government auditing standards.

Of the initial universe of 2,041 hospitals that met the selection 
criteria, 18 had closed by 2002 and 2 did not have emergency 
departments in fiscal year 2001, resulting in a final universe of 2,021 
hospitals. We sent our questionnaire to these hospitals and conducted 
follow-up mailings and telephone follow-up calls to nonrespondents. We 
obtained responses to the survey from 1,489 hospitals, for an overall 
response rate of about 74 percent. However, 7 of these hospitals did 
not return the section of the survey addressing emergency preparedness, 
leaving 1,482, for a response rate of about 73 percent for the 
questions of concern for the current report.[Footnote 29]

We analyzed the response rates by hospital size, type of ownership, and 
teaching status to assess if there was differential response among 
various categories of hospitals. The only statistically significant 
disproportionate response was from for-profit hospitals. Therefore we 
weighted responses to adjust for a lower response rate from investor-
owned (for-profit) hospitals to provide estimates representative of the 
entire universe of 2,021 hospitals in MSAs. Using the information 
provided by surveyed hospitals, we described the extent of emergency 
preparedness for bioterrorist incidents. We also examined the 
relationships between the extent of hospital bioterrorism preparedness 
and size of hospital as indicated by the number of inpatient staffed 
beds.

Questions in the survey focused on preparedness to respond to a 
bioterrorist event. Some of the responses are applicable more broadly 
to preparedness for all types of terrorist events, as well as for 
natural disasters or naturally occurring disease outbreaks. However, 
because the focus of this work was bioterrorism preparedness, we did 
not ask more detailed questions on other types of preparedness.

[End of section]

Appendix III: GAO Contact and Staff Acknowledgments:

GAO Contact:

Marcia Crosse, (202) 512-7119:

Acknowledgments:

In addition to the contact named above, George Bogart, Jennifer Cohen, 
Robert Copeland, Susan Lawes, Deborah Miller, and Roseanne Price made 
key contributions to this report.

[End of section]

Related GAO Products:

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Responding to Bioterrorism and Emerging Infectious Diseases. GAO-03-
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Homeland Security: New Department Could Improve Coordination but 
Transferring Control of Certain Public Health Programs Raises Concerns. 
GAO-02-954T. Washington, D.C.: July 16, 2002.

Homeland Security: New Department Could Improve Biomedical R&D 
Coordination but May Disrupt Dual-Purpose Efforts. GAO-02-924T. 
Washington, D.C.: July 9, 2002.

Homeland Security: New Department Could Improve Coordination but May 
Complicate Priority Setting. GAO-02-893T. Washington, D.C.: June 28, 
2002.

Homeland Security: New Department Could Improve Coordination but May 
Complicate Public Health Priority Setting. GAO-02-883T. Washington, 
D.C.: June 25, 2002.

Bioterrorism: The Centers for Disease Control and Prevention's Role in 
Public Health Protection. GAO-02-235T. Washington, D.C.: November 15, 
2001.

Bioterrorism: Review of Public Health Preparedness Programs. GAO-02-
149T. Washington, D.C.: October 10, 2001.

Bioterrorism: Public Health and Medical Preparedness. GAO-02-141T. 
Washington, D.C.: October 9, 2001.

Bioterrorism: Coordination and Preparedness. GAO-02-129T. Washington, 
D.C.: October 5, 2001.

Bioterrorism: Federal Research and Preparedness Activities. GAO-01-
915. Washington, D.C.: September 28, 2001.

West Nile Virus Outbreak: Lessons for Public Health Preparedness. GAO/
HEHS-00-180. Washington, D.C.: September 11, 2000.

Combating Terrorism: Need for Comprehensive Threat and Risk Assessments 
of Chemical and Biological Attacks. GAO/NSIAD-99-163. Washington, D.C.: 
September 14, 1999.

Combating Terrorism: Observations on Biological Terrorism and Public 
Health Initiatives. GAO/T-NSIAD-99-112. Washington, D.C.: March 16, 
1999.

FOOTNOTES

[1] U.S. General Accounting Office, Bioterrorism: Preparedness Varied 
Across State and Local Jurisdictions, GAO-03-373 (Washington, D.C.: 
Apr. 7, 2003).

[2] For information on emergency department capacity, see U.S. General 
Accounting Office, Hospital Emergency Departments: Crowded Conditions 
Vary among Hospitals and Communities, GAO-03-460 (Washington, D.C.: 
Mar. 14, 2003) and The Lewin Group, Emergency Department Overload: A 
Growing Crisis; The Results of the AHA Survey of Emergency Department 
(ED) and Hospital Capacity, April 2002. 

[3] Pub. L. No. 106-505,  102, 114 Stat. 2314, 2323 (2000).

[4] U.S. General Accounting Office, Bioterrorism: Federal Research and 
Preparedness Activities, GAO-01-915 (Washington, D.C.: Sept. 28, 2001) 
and GAO-03-373. 

[5] GAO-03-460.

[6] A ventilator is a mechanical device designed to perform part or all 
of the work of the lungs.

[7] TOPOFF, so named for the involvement of top officials of the U.S. 
government, was a set of exercises assessing readiness to respond to 
terrorist attacks. 

[8] Pneumonic plague is a contagious disease that can be spread from 
person to person by respiratory droplet. Its symptoms include cough and 
fever, progressing to respiratory failure and shock. Pneumonic plague 
can be treated with some success by antibiotics if treatment is given 
within 24 hours of the first symptoms. For untreated pneumonic plague, 
mortality approaches 100 percent.

[9] The Centers for Disease Control and Prevention (CDC) considers 
anthrax, botulism, plague, smallpox, tularemia, and hemorrhagic fever 
viruses as the six biological agents that pose the greatest potential 
threat for adverse public health impact and have a moderate to high 
potential for large-scale dissemination. 

[10] Quarantine facilities limit the freedom of movement of an 
individual and restrict visitors to prevent the spread of a disease to 
other members of the population, and could be created by separately 
housing affected individuals in an existing portion of a hospital. 
Isolation facilities provide a treatment setting that includes special 
or separate equipment such as air filters to limit the possibility of 
disease spread.

[11] U.S. General Accounting Office, Infectious Disease Outbreaks: 
Bioterrorism Preparedness Efforts Have Improved Public Health Response 
Capacity, but Gaps Remain, GAO-03-654T (Washington, D.C.: Apr. 9, 
2003), U.S. General Accounting Office, SARS Outbreak: Improvements to 
Public Health Capacity Are Needed for Responding to Bioterrorism and 
Emerging Infectious Diseases, GAO-03-769T (Washington, D.C.: May 7, 
2003), and Severe Acute Respiratory Syndrome: Established Infectious 
Disease Control Measures Helped Contain Spread, But a Large-Scale 
Resurgence May Pose Challenges, GAO-03-1058T. Washington, D.C.: July 
30, 2003.

[12] A. David Mangelsdorff, Chemical and Bioterrorism Preparedness 
Checklist (Chicago: American Hospital Association, Oct. 3, 2001), 
http://hospitalconnect.com/aha/key_issues/disaster_readiness/
resources/HospitalReady.html (downloaded Apr. 22, 2003).

[13] Center for the Study of Bioterrorism & Emerging Infections, Mass 
Casualty Disaster Plan Checklist: A Template for Healthcare Facilities 
(Washington, D.C.: Association for Professionals in Infection Control 
and Epidemiology, Inc., Oct. 1, 2001), http://www.apic.org/bioterror/
checklist.doc (downloaded Apr. 23, 2003).

[14] Disease surveillance is the monitoring of health-related data to 
identify, prevent, and control disease.

[15] GAO-03-373.

[16] Joint Commission on Accreditation of Healthcare Organizations, 
Health Care at the Crossroads: Strategies for Creating and Sustaining 
Community-wide Emergency Preparedness Systems (Oakbrook Terrace, Il.: 
2003).

[17] The funds were primarily appropriated by the Department of Defense 
and Emergency Supplemental Appropriations for Recovery from and 
Response to Terrorist Attacks on the United States Act, Pub. L. No. 
107-117, 115 Stat. 2230, 2314 (2002), and Departments of Labor, Health 
and Human Services, and Education, and Related Agencies Appropriations 
Act of Fiscal Year 2002, Pub. L. No. 107-116, 115 Stat. 2186, 2198. 

[18] The four eligible municipalities were Chicago, the District of 
Columbia, Los Angeles County, and New York City. Funding was also 
provided to five American territories: American Samoa, Guam, the 
Northern Marianas Islands, Puerto Rico, and the U.S. Virgin Islands.

[19] The four eligible municipalities are Chicago, the District of 
Columbia, Los Angeles County, and New York City. Funding will also be 
provided to five American territories: American Samoa, Guam, the 
Northern Marianas Islands, Puerto Rico, and the U.S. Virgin Islands, 
and to three freely associated states of the Pacific: Marshall Islands, 
Micronesia, and Palau.

[20] GAO-03-373.

[21] Staffed beds are the total facility beds set up and staffed as 
reported by hospitals in the American Hospital Association Annual 
Survey of Hospitals Database 2000. 

[22] The "worried well" are people who think they may be infected but 
in fact are not.

[23] GAO-03-373.

[24] A tabletop exercise is a type of simulation in which participants 
discuss scenarios and responses around a table or similar setting.

[25] GAO-03-373.

[26] We excluded federal hospitals, specialty hospitals, long-term care 
facilities, and hospitals located outside the 50 states or the District 
of Columbia.

[27] We focused on hospitals located in metropolitan areas designated 
as MSAs and Primary MSAs by the U.S. Census Bureau. For purposes of 
this report, we will refer to both types of areas as MSAs. In 2000, 
about 80 percent of the nation's population lived in MSAs.

[28] U.S. General Accounting Office, Hospital Emergency Departments: 
Crowded Conditions Vary among Hospitals and Communities, GAO-03-460 
(Washington, D.C.: Mar. 14, 2003).

[29] Questionnaires received after September 3, 2002, were not included 
in calculating our response rate and were excluded from our analyses.

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