Department of Health and Human Services
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
STATE  AND LOCAL PANDEMIC 
 
I P :  
NFLUENZA  REPAREDNESS   
 
 
M S  
EDICAL  URGE
 
 
 
 
 
Daniel R. Levinson  
Inspector General 
 
September 2009 
OEI-02-08-00210  Office of Inspector General 
http://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs.  This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits 
examine the performance of HHS programs and/or its grantees and contractors in carrying 
out their respective responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and 
mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud, waste, or abuse and promoting 
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 
of fraud and misconduct related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI utilizes its resources 
by actively coordinating with the Department of Justice and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to criminal 
convictions, administrative sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support for OIGs internal operations.  OCIG represents OIG in all civil and 
administrative fraud and abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program guidance, publishes fraud alerts, and provides other 
guidance to the health care industry concerning the anti-kickback statute and other OIG 
enforcement authorities.   E X E C U T I V E   S U M M A R Y  
OBJECTIVES   
To determine the extent to which selected States and localities have: 
1.  prepared for a medical surge in response to an influenza pandemic      
and  
2.  conducted and documented exercises that test their medical surge 
preparedness for an influenza pandemic.   
BACKGROUND   
An influenza pandemic is a global outbreak of a highly infectious 
influenza virus that can cause serious illness in humans.  The 
Department of Health and Human Services (HHS) estimates that even 
a mild influenza pandemic could cause between 2 and 7.4 million deaths 
worldwide.  In February 2008, the Assistant Secretary for Preparedness 
and Response (ASPR) within HHS asked the Office of Inspector General 
to evaluate State and local preparedness for influenza pandemic, 
particularly with regard to medical surge and vaccine and antiviral 
drug distribution and dispensing.   
Since 2002, HHS, primarily through ASPR and the Centers for Disease 
Control and Prevention (CDC), has provided more than $8 billion for 
programs to enhance their emergency preparedness for large-scale 
public health emergencies.  In addition, HHS provided $600 million in 
supplemental funding specifically for pandemic influenza preparedness.   
If a severe pandemic occurs, it will affect much of the country at the 
same time, so medical resourcessuch as hospital beds, medical 
equipment, and personnelwill likely be scarce.  The ability to rapidly 
respond to an increased demand for medical resources is often referred 
to as a medical surge.  This study focuses on the following five key 
components of medical surge that are based on guidance from ASPR and 
CDC:  (1) coordination among stakeholders; (2) recruitment and 
management of medical volunteers; (3) acquisition and management of 
medical equipment;  
(4) development of alternate care sites; and (5) identification of 
guidelines for altering triage, admission, and patient care.   
This study is based on a purposive sample of 5 States and 10 localities 
and presents a snapshot of these States and localities preparedness for 
an influenza pandemic as of late summer 2008.  The study is based on a 
review of documentation from ASPR, CDC, and the selected States and 
  OEI-02-08-00210  STATE AND LOCAL PANDEMIC INFLUENZA PREPAREDNESS:  MEDICAL SURGE  i  E X E C U T I V E   S U M M A R Y  
localities, as well as structured in-person interviews with key officials in 
each of the selected States and localities.   
FINDINGS 
All of the selected localities had established partnerships to 
prepare for a medical surge; however, the degree to which 
coordination occurred varied.  As of late summer 2008, all  
10 localities had developed committees to help plan for a pandemic, as 
well as health care coalitions to coordinate the efforts of health care 
facilities.  In addition, all localities had started to include hospitals in 
their emergency response planning.  Although these partnerships 
helped to prepare for a medical surge, the degree to which coordination 
occurred varied among the 10 localities.   
Fewer than half of the selected localities had started to recruit 
medical volunteers, and none of the five States had implemented 
an electronic system to manage them.  Four localities had started to 
recruit, register, and train medical volunteers.  All four, however, had 
concerns about using volunteers.  In addition, none of the five States 
had fully implemented an electronic system for managing medical 
volunteers.  States were required by ASPR to have electronic systems to 
register medical volunteers and verify credentials by August 2009.  
All of the selected localities had acquired limited medical 
equipment for a pandemic, but only three of the five States had 
electronic systems to track beds and equipment.  All 10 localities 
had acquired limited caches of medical equipment; however, many 
experienced difficulties with managing this equipment.  In addition, 
only three of the five States had implemented electronic systems to 
track available hospital beds and medical equipment during an 
emergency.   
Most of the selected localities were in the early stages of planning 
for alternate care sites.  Alternate care sites are preselected facilities, 
such as schools or convention centers, that have been identified for 
potential use during emergencies to help alleviate overcrowding in 
hospitals.  Nine localities had either identified or were in the process of 
identifying alternate care sites to be used in a pandemic; however, few 
had signed formal agreements.  None of the localities that were 
planning to use alternate care sites had plans that included the scope of 
care and how these sites would be managed, staffed, and supplied. 
 
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Most of the selected localities had not identified guidelines for 
altering triage, admission, and patient care; many cited liability 
concerns.  During a pandemic, health care professionals may need to 
alter how they provide medical care by allocating scarce resources in a 
manner that saves the greatest number of lives.  Nine localities had not 
identified guidelines for altering triage, admission, and patient care 
during a pandemic.  Seven of these localities noted that providers in 
their localities were concerned that they would be legally at risk if they 
were to alter their standards for triage, admission, or patient care, and 
all nine reported that they wanted additional State or Federal guidance. 
All of the selected localities conducted medical surge exercises; 
however, none consistently documented the lessons learned.  
Localities conducted between one and seven medical surge exercises 
over a 2-year period.  Most of these exercises were discussion-based, 
rather than operations-based.  Although localities are encouraged to 
document lessons learned during exercises through the creation of  
after-action reports and improvement plans, none consistently 
completed these documents for their exercises.  In addition, the existing 
documentation that we reviewed showed that localities needed to make 
improvements within the five medical surge components.   
RECOMMENDATIONS 
Based on these findings, we recommend that ASPR, in collaboration 
with CDC: 
Work with States and localities to improve their efforts within each 
of the five components of medical surge that we reviewed. 
  ASPR should continue to emphasize the importance of coordination and 
involving a wide array of stakeholders in medical surge and pandemic 
planning.   
  ASPR should continue to emphasize the importance of recruiting, 
registering, and training medical volunteers for use in a pandemic.   
  ASPR should continue to emphasize the importance of managing 
medical equipment currently being stockpiled for a public health 
emergency, such as a pandemic.   
  ASPR should continue to emphasize the importance of planning for 
alternate care sites for use during a pandemic.     
  OEI-02-08-00210  STATE AND LOCAL PANDEMIC INFLUENZA PREPAREDNESS:  MEDICAL SURGE  iii  E X E C U T I V E   S U M M A R Y  
 
  ASPR should emphasize the importance of identifying and adopting 
guidelines for altering triage, admission, and patient care during a 
pandemic.     
Ensure that States and localities consistently document the lessons 
learned from preparedness exercises that address medical surge.  
Given the importance of exercises in strengthening preparedness, ASPR, 
in collaboration with CDC, should ensure that States and localities 
consistently document the lessons learned from all medical surge exercises 
that require documentation.   
Address the issue of legal protections for medical professionals and 
volunteers who respond to public health emergencies, such as an 
influenza pandemic.  ASPR should consider working with States to 
develop appropriate legal protections for medical professionals and 
volunteers who respond to public health emergencies and who may need to 
alter standards of care.  ASPR should also consider the feasibility of 
Federal legislation in this area.   
Facilitate the sharing of information and emerging practices 
among States and localities.  ASPR, in collaboration with CDC, 
should collect information on emerging practices from States and 
localities, as well as experts in the field, to further improve medical 
surge preparedness.  ASPR should employ a variety of strategies to 
facilitate the sharing of this information and emerging practices 
among States and localities.   
Provide training and technical assistance to States and localities on 
key issues.  ASPR, in collaboration with CDC, should address specific 
State and local challenges, such as identifying alternate care sites, 
managing medical equipment, and identifying guidelines for alternate 
standards of care.   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
ASPR concurred with all five of our recommendations.  CDC did not 
formally comment, but did provide technical comments.  We made 
changes to the final report based on CDCs technical comments, as 
appropriate.   
 
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EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
 
 
 
 
I N T R  O DUC T IO N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 
 
 
F I N D IN G S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 
  All of the selected localities had established partnerships to            
  prepare for a medical surge; however, the degree to which 
  coordination occurred varied . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 
  Fewer than half of the selected localities had started to recruit 
  medical volunteers, and none of the five States had implemented       
  an electronic system to manage them . . . . . . . . . . . . . . . . . . . . . . 13 
All of the selected localities had acquired limited medical           
equipment for a pandemic, but only three of the five States had 
electronic systems to track beds and equipment. . . . . . . . . . . . . . 15 
  Most of the selected localities were in the early stages of          
  planning for alternate care sites . . . . . . . . . . . . . . . . . . . . . . . . . . 17 
  Most of the selected localities had not identified guidelines for   
  altering triage, admission, and patient care; many cited liability 
  concerns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 
  All of the selected localities conducted medical surge exercises; 
  however, none consistently documented the lessons learned . . . . 20 
 
 
R E C O MMEN D A T ION S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 
  Agency Comments and Office of Inspector General Response . . . 27 
 
 
APPENDIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 
  A:  Selected States and Localities. . . . . . . . . . . . . . . . . . . . . . . . . . 28 
  B:  Agency Comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 
 
 
A C K NO WL E D G M E N T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 
   TI NA TB RL OE D  OU FC  T CI OO NN T E N T S  
OBJECTIVE 
To determine the extent to which selected States and localities have: 
1.  prepared for a medical surge in response to an influenza pandemic 
and  
2.  conducted and documented exercises that test their medical surge 
preparedness for an influenza pandemic.   
BACKGROUND 
An influenza pandemic is a global outbreak of a highly infectious 
influenza virus that can cause serious illness in humans.1  HHS 
estimates that even a mild influenza pandemic could cause between  
2 and 7.4 million deaths worldwide.2  In June 2009, after human cases 
of a novel H1N1 influenza were identified in the United States and 
internationally, the World Health Organization raised its influenza 
pandemic alert level to Phase 6, indicating that a pandemic is 
underway.3  Although scientists cannot predict this pandemics severity, 
it has highlighted the importance of ongoing emergency preparedness 
efforts.   
In February 2008, the Assistant Secretary for Preparedness and 
Response (ASPR) within HHS asked the Office of Inspector General 
(OIG) to evaluate State and local preparedness for influenza pandemic, 
particularly with regard to medical surge and vaccine and antiviral 
drug distribution and dispensing.   
This evaluation focuses on the extent to which selected States and 
localities have prepared for a medical surge during a pandemic.  
Medical surge is a rapid expansion of the health care system in response 
to an event that requires resourcessuch as hospital beds, medical 
equipment, and personnelthat exceed what the normal medical 
 
1 Department of Health and Human Services (HHS),  Flu Terms Defined.  Available 
online at http://www.pandemicflu.gov.  Accessed on February 17, 2009.  
2 HHS, Why are pandemics such dreaded events?  Available online at 
http://www.pandemicflu.gov/faq/pandemicinfluenza/1108.html.  Accessed on February 17, 
2009. 
3 World Health Organization, World now at the start of 2009 influenza pandemic.  
Available online at http://www.who.int/mediacentre/news/statements/2009/h1n1_pandemic 
_phase6_20090611/en/index.html.  Accessed on August 10, 2009.   
 
  OEI-02-08-00210  STATE AND LOCAL PANDEMIC INFLUENZA PREPAREDNESS:  MEDICAL SURGE  1  I N T R O D U C T I O N  
 
infrastructure can provide.4  A second OIG evaluation focuses on the 
extent to which selected localities have prepared for vaccine and 
antiviral drug distribution and dispensing during a pandemic.5  In 
addition, OIG is auditing three States to determine whether certain 
expenditures used to prepare for an influenza pandemic complied with 
Federal requirements.6 
HHS Support of State and Local Preparedness Efforts  
Since 2002, HHS has provided more than $8 billion for programs to 
enhance their emergency preparedness for large-scale public health 
emergencies.7  HHS has distributed this funding primarily through 
cooperative agreements under two programsASPRs HPP8 and the 
Centers for Disease Control and Preventions (CDC) PHEP.9  In 
addition to providing general emergency preparedness funds, HHS has 
provided $600 million in supplemental funding specifically for 
improving preparedness for an influenza pandemic.  
 
4 The CNA Corporation, Medical Surge Capacity and Capability:  A Management 
System for Integrating Medical and Health Resources During Large-Scale Emergencies,   
August 2004, p. I 5. 
5 OIG, Local Pandemic Influenza Preparedness:  Vaccine and Antiviral Drug 
Distribution and Dispensing, OEI-04-08-00260. 
6 OIG, Review of Vermonts Pandemic Influenza Expenditures for the Period August 31, 
2005, Through June 30, 2008, A-01-08-01500, June 25, 2009; Review of Washington 
State's Pandemic Influenza Expenditures for the Period August 31, 2005, Through June 30, 
2008, A-09-08-01006, August 21, 2009.  OIG is also auditing pandemic influenza 
expenditures in Georgia. 
7 HHS, HHS Announces $896.7 Million in Funding to States for Public Health 
Preparedness and Emergency Response.  Available online at 
http://www.hhs.gov/news/press/2007pres/07/pr20070717c.html.  HHS also provided an 
additional $1 billion in Public Health Emergency Preparedness Program (PHEP) and 
Hospital Preparedness Program (HPP) funds in 2008.  See HHS, HHS Provides More Than 
$1 Billion to Improve All Hazards Public Health.  Available online at 
http://www.hhs.gov/news/press/2008pres/06/20080603a.html.  Accessed on March 6, 2009.    
8 The administration of HPP was transferred to ASPR from the Health Resources and 
Services Administration (HRSA) in December 2006.  (See 42 U.S.C.  300hh-10, as added by 
P.L. No. 109-417, Title I,  102(a)(3)).  Activities under HPP are currently authorized by  
42 U.S.C.  247d-3a and 247d-3b. 
9 CDC has cited various authorities for PHEP and PHEP supplemental funding.  CDC is 
currently relying on section 319C-1 of the Public Health Service Act (42 U.S.C.  247d-3a) 
for all of these grant awards. 
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The Secretary of HHS has been designated the lead official for all 
Federal public health and medical response in the event of a public 
health emergency.10  ASPR is the primary agency within HHS 
responsible for improving medical surge preparedness.  ASPR provides 
funding and guidance through HPP to improve the response of the 
health care system during public heath emergencies.11  CDC generally 
plays a supporting role in medical surge preparedness by focusing on 
improving the response of the public health system during an 
emergency, such as an influenza pandemic.  
The focus of both HPP and PHEP funding is to build the capability of 
the health care and public health systems to minimize the number of 
deaths, long term disabilities, injuries, and hospitalizations from events, 
such as pandemics.12  In general, HPP and PHEP guidance require that 
States prioritize preparedness activities and outline how they will spend 
the funds.13  The guidance generally allows States to specify in their 
grant applications the activities that they intend to complete to improve 
their preparedness.14  As these programs have evolved, the guidance 
has often emphasized varying program priorities.  In addition, although 
Federal funding and guidance are provided to States, many of the 
activities needed to prepare for an influenza pandemic are carried out 
by localities.   
 
 
10 This authority was established with the passage of the 2006 Pandemic and  
All-Hazards Preparedness Act, P.L. No. 109-417,  201, 42 U.S.C.  247d.   
11 Funding for both HPP and PHEP was provided to the 50 States; Washington, DC;  
five territories (Puerto Rico, the Virgin Islands, American Samoa, Commonwealth of the 
northern Mariana Islands, and Guam); the Pacific Freely Associated States (Republic of the 
Marshall Islands, Republic of Palau, and the Federated States of Micronesia); and the 
localities of Chicago, Los Angeles County, and New York City.  For the purposes of this 
report, we refer to these entities as States. 
12 HRSA, National Bioterrorism Hospital Preparedness Program (hereinafter referred to 
as HPP Fiscal Year (FY) 06 guidance), FY 2006, p.5; CDC, Pandemic Influenza Guidance 
Supplement to the 2006 Public Health Emergency Preparedness Cooperative Agreement 
Phase II (hereinafter referred to as PHEP Phase II guidance), p. 5.   
13 HPP FY 06 guidance, pp. 29-30; ASPR, Announcement of Availability of Funds for the 
Hospital Preparedness Program, Pandemic Influenza Supplement for Medical Surge 
Capacity and Capability, p. 2; PHEP Phase II guidance, p. 9. 
14 Ibid. 
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Medical Surge in Response to a Pandemic 
 If a severe pandemic occurs, it will affect much of the country at the 
same time, so medical resourcessuch as hospital beds, medical 
equipment, and personnelwill likely be scarce.15  The ability to 
rapidly respond to this increased demand for medical resources is often 
referred to as medical surge.  This study focuses on the following five 
key components of medical surge that were identified in HPP and PHEP 
guidance:  (1) coordination among stakeholders; (2) recruitment and 
management of medical volunteers; (3) acquisition and management of 
medical equipment; (4) identification of alternate care sites; and (5) 
identification of guidelines for altering triage, admission, and patient 
care.     
Coordination among stakeholders:  HPP and PHEP guidance 
consistently emphasize that medical surge preparedness requires 
coordination among a variety of public and private stakeholders, 
including hospitals and other health care facilities, public health 
departments, and emergency management departments.  HPP and 
PHEP guidance also encourage States and localities to establish 
pandemic influenza coordinating committees and health care coalitions 
to help plan for a pandemic.  Additionally, these documents encourage 
localities to integrate the efforts of private health care facilities with 
those of the local departments of public safety, emergency management, 
and public health.16 
Recruitment and management of medical volunteers:  In the event of a 
pandemic, States and localities may be forced to rely on large numbers of 
medical volunteers.  HPP guidance encourages States and localities to 
recruit, register, and train medical volunteers prior to a pandemic as part 
of the Emergency System for Advance Registration of Volunteer Health 
Professionals (ESAR-VHP) program.17  Additionally, the guidance 
 
15 Agency for Healthcare Research and Quality (AHRQ), AHRQ Publication No. 07-0001, 
Mass Medical Care with Scarce Resources:  A Community Planning Guide (2007).  
Available online at http://www.ahrq.gov/research/mce/mceguide.pdf.  Accessed on  
April 23, 2008. 
16 ASPR, Announcement of Availability of Funds for the Hospital Preparedness Program, 
Pandemic Influenza Supplemental for Medical Surge Capacity and Capability for Budget 
Period October 31, 2007October 31, 2008, p. 4 (hereinafter referred to as HPP FY 07 
guidance); PHEP Phase II guidance, p. 3. 
17 Note that HPP guidance references additional guidance in the following document:  
HRSA, ESAR-VHP Program Interim Technical and Policy Guidelines, Standards, and 
Definitions, Version 2, June 2005.  ASPR plans to release Version 3 of this guidance in 
2009. 
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required States to develop electronic systems to register medical 
volunteers and verify credentials by August 2009.18   
Acquisition and management of medical equipment:  During a severe 
pandemic, medical equipment will likely be scarce.  Both HPP and 
PHEP supplemental funding can be used to purchase medical 
equipment at the State and local levels.  Localities are generally 
responsible for storing, maintaining, and transporting this medical 
equipment.  In addition, HPP requires States to maintain a system that 
enables them to report to HHS the number of available hospital beds.19  
It also encourages States to make these systems electronic; however, 
States have the option of manually entering the data they receive from 
hospitals into an HHS Web site.  In addition, States are encouraged to 
establish interoperable inventory-tracking systems that assist with the 
management of medical equipment during an emergency.20 
Development of alternate care sites:  Alternate care sites are preselected 
facilitiessuch as schools or convention centersthat have been identified 
for potential use during emergencies to help alleviate overcrowding in 
hospitals.  They can also be mobile alternate care sites that are  
preequipped with tents and beds and can be set up quickly in various 
locations.  HPP and PHEP guidance encourage hospitals, in conjunction 
with other community partners, to identify appropriate locations for 
alternate care sites.21  Before being able to use these sites, localities need 
to engage in a significant amount of planning.  Such planning generally 
consists of determining the scope of care that will be provided at the site in 
an emergency and establishing how the site will be managed, staffed, and 
supplied.    
 
18 HPP FY 07 guidance pp. 2-3; 1-year extension provided for in ASPR, Announcement of 
Availability of Funds for HPP, FY 08, p. 12. 
19 HPP FY 07 guidance.  States were required to have such reporting capabilities
referred to as the standards for Hospital Available Beds for Emergencies and Disastersby 
August 8, 2008.   
20 Note that HPP guidance requires States to be compliant with the National Incident 
Management System, which encourages States to have interoperable systems in place to 
track equipment.  In the future, these systems will be required for States.  See  Federal 
Emergency Management Agency, IS-700.a National Incident Management System, An 
Introduction, I-700.a, Unit 5.  Available online at:  
http://training.fema.gov/EMIWeb/IS/is700alst.asp.  Accessed on May 21, 2009.    
21 PHEP Phase II guidance, p. 32.  The guidance also encourages States to use a tool 
developed by AHRQ to help identify facilities that can be used as alternate care sites.   
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Identification of guidelines for altering triage, admission, and patient care:  
A severe pandemic will likely require changes to how medical care is 
provided.  Physicians and other health care professionals may need to 
alter triage, admission, and patient care.  Such alterations are referred to 
as altered standards of care, which generally require allocating scarce 
equipment, supplies, and personnel in a manner that saves the greatest 
number of lives, as opposed to the traditional focus of treating the sickest 
or most injured patients first.22  In 2004, HHS developed 
recommendations to States and localities for how to alter patient care, 
emphasizing that such efforts should involve unified local and regional 
planning.23  Specifically, localities are encouraged to identify and adopt 
guidelines for altering triage, admission, and patient care to ensure that 
all hospitals and other health care providers are making uniform decisions 
during a pandemic.  In addition, the American Health Lawyers Association 
(AHLA), in cooperation with CDC and OIG, developed a checklist that 
encourages health care providers to develop altered standards of care that 
may become necessary in a pandemic.24  
Exercises To Address Medical Surge 
States and localities conduct exercises to test and improve their 
medical surge preparedness.  HPP and PHEP guidance require States 
to conduct medical surge exercises.25  Localities may participate in 
State exercises or conduct their own exercises.   
Exercises generally fall into two categories.  Discussion-based 
exercises enable participants to become familiar with current plans, 
policies, and procedures.  In contrast, operations-based exercises 
enable participants to execute plans, policies, and procedures in order 
to clarify roles and responsibilities and identify resource gaps.26  
PHEP guidance suggests using discussion-based exercises to identify 
 
22 AHRQ,  Altered Standards of Care in Mass Casualty Events, April 2005.  Available 
online at http://www.ahrq.gov/research/altstand/altstand1.htm.  Accessed on March 6, 2009.   
23 Ibid.   
24 This document also provides a comprehensive list of potential legal issues that health 
care providers may face during an influenza pandemic.  See AHLA, Community Pan-Flu 
Preparedness:  A Checklist of Key Legal Issues for Healthcare Providers, 2008.  Available 
online at http://www.healthlawyers.org/panfluchecklist.  Accessed on May 13, 2009. 
25 HPP guidance required that States conduct at least one medical surge exercise by 
August 2008.  PHEP required States to conduct at least one medical surge exercise by 
August 2007.  HPP FY 07 guidance, pp. 1517; PHEP Phase II guidance, pp. 1011. 
26 Homeland Security Exercise and Evaluation Program (HSEEP).  Available online at 
https://hseep.dhs.gov/pages/1001_HSEEP7.aspx.  Accessed on March 6, 2009. 
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and address gaps in preparedness plans before conducting more 
resource-intensive operations-based exercises.27 
HPP and PHEP guidance also encourage States to conduct exercises 
in accordance with the HSEEP program.28  HSEEP requires 
participants to create an after-action report and an improvement plan 
for each exercise.  After-action reports include the exercise objectives, 
participant observations, and general recommendations.  
Improvement plans incorporate the lessons learned during the 
exercise and include specific corrective actions, the responsible 
parties, and dates for their completion.  
Related Work  
In 2009, the Center for Biosecurity of the University of Pittsburgh 
Medical Center, under contract with ASPR, released a report on the 
impact of HPP on hospital preparedness from 2002 to 2007.29  It found 
that disaster preparedness of individual hospitals had improved 
significantly throughout the country since the start of HPP.   
Specifically, it found that the emergence of health care coalitions 
created a foundation for health care preparedness, but that health care 
planning for catastrophic emergencies was still in its early stages, 
particularly with regard to altering standards of care.   
In 2008, the Government Accountability Office (GAO) released a report 
that found that selected States and localities had developed pandemic 
influenza plans.30  These States and localities had also conducted or 
participated in at least one exercise to test their plans.  Further, GAO 
found that according to HHSs review of these plans, States had major 
gaps in many areas, including medical surge.  
In 2008, GAO released another report that found that the Federal 
Government had provided funding, written guidance, and other 
assistance, such as holding conferences, to help States prepare for 
 
27 PHEP Phase II guidance, p. 6. 
28 HPP FY 07 guidance, pp. 1617; PHEP Phase II guidance, p. 4.  Beginning in August 
2008, HSEEP compliance was required for all exercises associated with HPP or PHEP 
funding. 
29 Center for Biosecurity of the University of Pittsburgh Medical Center, Hospitals 
Rising to the Challenge:  The First Five Years of the U.S. Hospital Preparedness Program 
and Priorities Going Forward, March 2009. 
30 GAO, Influenza Pandemic:  Federal Agencies Should Continue to Assist States to 
Address Gaps in Pandemic Planning, GAO-08-539, June 2008. 
  OEI-02-08-00210  STATE AND LOCAL PANDEMIC INFLUENZA PREPAREDNESS:  MEDICAL SURGE  7  II NN TT RR OO DD UU CC TT II OO NN   
medical surge in a mass casualty event. 31  GAO reported that the  
20 States it reviewed were planning for medical surge at the State 
level and had made efforts in increasing hospital capacity, identifying 
alternate care sites, and registering medical volunteers, but that 
fewer were planning for altered standards of care.  GAO further noted 
that these 20 States continued to face challenges in preparing for 
medical surge in a mass casualty event.   
METHODOLOGY 
This review determines how selected States and localities have prepared 
for medical surge in response to an influenza pandemic and the extent to 
which they have conducted and documented exercises that test their 
preparedness.  It presents a snapshot of selected States and localities 
preparedness for an influenza pandemic as of late summer 2008.  This 
review is based on data from two sources:  (1) a review of documentation 
from ASPR, CDC, and the selected States and localities; and (2) structured 
in-person interviews with key officials in each of the selected States and 
localities.   
Selection of Sampled States and Localities 
We selected a purposive sample of five States based on the following 
factors:  health department structure, population density, geographic 
distribution, and input from ASPR and CDC.  We selected one State 
included in related OIG studies and eliminated other States included in 
recent GAO work related to this evaluation.  The States we selected 
were Maine, Missouri, South Dakota, Virginia, and Washington.  In 
each State, we selected the largest Metropolitan Statistical Area (MSA) 
and then selected the most populated city within that MSA.  We also 
selected one low- to medium-sized city in each State.  We did not select 
localities in counties that were adjacent to each other to ensure that 
localities were in different regional planning areas.  See Appendix A for 
a list of the selected localities.   
Data Collection 
Selection of medical surge components:  We selected the following five 
key components of medical surge based on a review of HPP and PHEP 
guidance and input from officials at CDC and ASPR:  (1) coordination 
 
31 GAO, Emergency Preparedness:  States Are Planning for Medical Surge, but Could 
Benefit from Shared Guidance for Allocating Scarce Medical Resources, GAO-08-668,  
June 2008. 
  OEI-02-08-00210  STATE AND LOCAL PANDEMIC INFLUENZA PREPAREDNESS:  MEDICAL SURGE  8  I N T R O D U C T I O N  
among stakeholders; (2) recruitment and management of medical 
volunteers; (3) acquisition and management of medical equipment;       
(4) identification of alternate care sites; and (5) identification of 
guidelines for altering triage, admission, and patient care.  
State and local documentation:  To determine how selected States and 
localities have prepared for a medical surge, we first requested 
documentation from ASPR and CDC.  Specifically, we requested HPP, 
HPP supplemental, and PHEP supplemental applications and progress 
reports that covered the time between 2006 and 2008 for each of the five 
selected States.  We also requested any assessments that ASPR and CDC 
conducted of these documents.   
In addition, from each selected State and locality, we requested all 
available documentation related to the five components of medical surge 
that we reviewed.  These documents included States and localities 
pandemic influenza plans and various other documents, such as committee 
meeting notes, memoranda of understanding, and descriptions of 
equipment.  We also requested all available documentation about the 
exercises that these States and localities conducted from August 2006 to 
August 2008 that were related to these five components of medical surge, 
including any after-action reports and improvement plans.32    
Structured interviews with State and local officials:  We conducted 
structured in-person interviews with officials responsible for coordinating 
medical surge in each of the 5 States and 10 localities.  At the State level, 
these officials typically included State HPP and PHEP coordinators and 
State emergency preparedness exercise coordinators.  At the local level, we 
determined how each State distributed its HPP and PHEP funds to its 
localities and identified the key local officials responsible for coordinating 
medical surge activities.  These officials typically included representatives 
involved in pandemic planning activities as well as representatives from 
local public health departments and hospitals.  In a few localities, 
representatives from emergency management services were also present.  
We conducted the interviews between July and September 2008.  
 
32 For the purpose of our review, we included exercises that localities either conducted or 
participated in (including exercises that the State conducted in which the selected localities 
participated).  We did not include routine drills because they are limited to an exercise of a 
single entity and function.  We also did not include workshops as they are generally focused 
on achieving a particular objective, such as developing a new draft plan or policy.   
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During our interviews, we asked State and local officials about their 
preparedness activities for medical surge and about the exercises they 
had conducted within the five components that we reviewed.  Our 
discussions with State officials focused on the States role in each of the 
five components as well as in conducting exercises.  Our discussions 
with local officials focused on the localities progress and challenges 
within each of the five components, as well as the localities exercise 
programs.  Throughout the report, we use the term States to refer to 
the State officials that we interviewed and localities to refer to the 
local and regional officials that we interviewed. 
Data Analysis 
To determine how the selected States and localities have prepared for a 
medical surge, we relied on both the State and local documentation we 
collected, as well as the responses from the structured interviews with 
State and local officials.  We compared the documentation to the 
information gathered during our structured interviews and looked for 
consistency among the sources of data.  We also asked for additional 
documentation, when appropriate, to validate certain responses about 
States and localities preparedness activities.  For example, we 
reviewed memoranda of understanding or other documentation to verify 
that localities had formal agreements in place that would allow them to 
set up alternate care sites.  We also reviewed meeting notes and agenda 
to verify that localities coordinated with certain entities.  In addition, 
we compared the responses of the State officials to those of the local 
officials.  We also looked for corroboration among the various officials 
present at each interview.  To determine the extent to which States and 
localities have conducted and documented exercises that test their 
medical surge preparedness, we relied primarily on the documentation 
we collected from the States and localities, including any after-action 
reports and improvement plans.  
Limitations 
This study is based on a purposive sample of five States and two 
localities within each of these States.  The findings cannot be projected 
to other States and localities.  In addition, the five components of 
medical surge that we reviewed do not encompass all aspects of medical 
surge preparedness.  For example, other aspects of medical surge may 
include preparedness activities designed to improve hospital 
evacuations and fatality management.    
 
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Standards 
This study was conducted in accordance with the Quality Standards for 
Inspections approved by the Council of the Inspectors General on 
Integrity and Efficiency. 
 
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All of the selected localities had established  HPP and PHEP guidance 
partnerships to prepare for a medical surge;  emphasize that medical surge 
however, the degree to which coordination  preparedness necessitates 
coordination among a variety of 
occurred varied  
public and private stakeholders.  
These documents also encourage States and localities to establish 
pandemic influenza coordinating committees and health care coalitions 
to help plan for a pandemic.  Additionally, the documents encourage 
localities to integrate the efforts of health care facilities with the efforts 
of agencies for public safety, emergency management, and public health. 
All 10 localities had developed committees to help plan for a pandemic 
As of late summer 2008, all 10 localities we reviewed had established 
committees to help plan for an influenza pandemic.  These committees 
generally included representation from health care, public health, 
emergency management, public safety, local schools, and private 
industry.  These committees typically were responsible for developing 
the localities pandemic influenza response plans.  They also commonly 
discussed issues important to pandemic planning, such as the use of 
volunteer health care personnel and alternate care sites, as well as how 
best to use funds from State and Federal agencies to prepare for a 
pandemic.  
Although all 10 localities had established such committees, the degree to 
which coordination occurred varied among the localities.  In some 
localities, the committees were actively engaged and met monthly, whereas 
in other localities they met less frequently.  In addition, the degree to 
which the local health departments participated in these preparedness 
committees also varied among localities.  Many localities reported 
challenges with keeping necessary partners engaged in pandemic 
planning.  As a few noted, planning was often fragmented because there 
were multiple agencies and different funding streams involved.  
All 10 localities had developed health care coalitions to coordinate the 
efforts of health care facilities 
All 10 localities had developed health care coalitions to coordinate the 
preparedness efforts of health care facilities and providers and to 
develop plans for medical emergencies, such as a pandemic.  
Localities most commonly reported that the most active participants 
in their coalitions were local and regional hospitals.  However, some 
localities reported that keeping hospitals engaged in the coalitions 
  OEI-02-08-00210  STATE AND LOCAL PANDEMIC INFLUENZA PREPAREDNESS:  MEDICAL SURGE  12  F I N D I N G S  
activities was difficult, as hospitals were often strained by increasing 
preparedness requirements, decreasing funding, and the everyday 
pressures to stay in business.   
The extent to which localities had started to include other types of health 
care providers in their coalitions differed.  Many localities were in the 
early stages or had not attempted to include nonhospital providers at all.  
For example, only 3 of the 10 localities had coalitions that involved home 
health care agencies, 5 localities had coalitions that involved nursing 
homes, and 5 localities had coalitions that involved local heath care clinics.  
In addition, several localities emphasized that their goal in working with 
these other health care providers was mainly educational.  
All 10 localities had started to include hospitals in their emergency 
response planning 
All 10 localities had started to include hospitals in their emergency 
response planning.  Until recently, hospitals were not typically part of 
localities emergency response planning.  However, several localities noted 
that the relationships between hospitals and emergency management, 
public safety, and public health officialsalthough relatively newwere 
critically important to the localities pandemic planning response.  As one 
hospital official stated, we need to play a bigger role in emergency 
planning, especially if we are facing something like a pandemic.  
At the same time, the degree to which hospitals were included in 
emergency response planning varied.  A few localities had well-established 
systems for sharing information between emergency management agencies 
and hospitals.  Other localities were just beginning to develop these 
relationships, and several hospitals reported that they had not been fully 
integrated into their localities emergency response planning.   
 
Medical staff will likely be scarce 
Fewer than half of the selected localities had 
during a severe pandemic, and 
started to recruit medical volunteers, and none 
localities may need to rely on 
of the five States had implemented an  
medical volunteers to help respond 
electronic system to manage them 
to the increased demands upon the 
medical infrastructure.  To prepare for this, HPP guidance encourages 
States and localities to recruit, register, and train medical volunteers as 
part of the ESAR-VHP program.  HPP guidance also required States to 
develop electronic systems to register medical volunteers and verify 
credentials by August 2009. 
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Four localities had started to recruit, register, and train medical volunteers 
As of late summer 2008, 4 of the 10 localities had started to recruit, 
register, and train medical volunteers to be used in a pandemic.  These 
localities planned to use their volunteers primarily in alternate care 
sites and, to a lesser degree, in hospitals.  Two of the remaining 
localities were in the early stages of developing policies and procedures 
to recruit volunteers, whereas four others had no plans to recruit or 
train volunteers, as they intended to use volunteers from other 
organizations, such as the Red Cross, or rely on spontaneous volunteers.   
The four localities that had started to recruit volunteers reported 
registering between 38 and 200 volunteers each.  To recruit volunteers, 
they typically used media advertisements and in-person presentations 
at health fairs and medical association meetings.  They often targeted 
specific groups, such as retired medical professionals; school nurses; 
medical and nursing school students; and medical societies.  To register 
their volunteers, all four localities had some type of background check 
that typically involved interviews, fingerprinting, and the verification of 
medical licenses.  All four localities also offered training to volunteers in 
areas such as first aid techniques.  In addition, two of these localities 
used their volunteers on a routine basis, such as helping to staff 
seasonal influenza clinics.   
The four localities had several factors in common that may have helped 
them develop their volunteer programs.  These factors included having 
a paid volunteer coordinator, using an existing Federal volunteer 
program called the Medical Reserve Corps,33 and having multiple 
sources of funding to help support their volunteer programs.    
At the same time, these four localities expressed a number of concerns 
about using volunteers.  They were concerned primarily that their 
volunteers would not show up during a pandemic because of competing 
work or other volunteer commitments or because of fears that the 
volunteers would not be legally protected during a pandemic.  They also 
noted that volunteers may not have worked in a clinical setting 
recently, may not have current medical licenses, or may have physical 
limitations, thereby limiting the role that the volunteers could play 
 
33 The Medical Reserve Corps in the Office of the Surgeon General is a nationwide 
program that uses medical and public health professionals in a volunteer capacity to 
improve the health and safety of communities.  Medical Reserve Corps are local units that 
strengthen the public health infrastructure of their communities.   
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during a pandemic.  Other concerns focused on the amount of resources 
needed to maintain a successful volunteer program.  
None of the five States had fully implemented an electronic system for 
managing medical volunteers 
As of late summer 2008, none of the five States had fully implemented 
an electronic system to manage volunteers.  As noted earlier, HPP 
required States to have electronic systems for managing medical 
volunteers by August 2009.  Four of the five States reported that they 
were in the process of selecting system software, developing their 
systems, or writing policies for using their systems.  The remaining 
State reported that its system was not fully operational in that it was 
still developing the ability to verify the credentials of volunteers. 
Even though these systems were not fully operational, a number of the 
localities expressed concerns about using their States systems.  Two 
localities that had their own systems for registering and credentialing 
volunteers were reluctant to transition to the new State system.  In 
addition, three localities expressed concerns that their States may use 
the system to deploy local volunteers without alerting the localities.  
 
During a severe pandemic, 
All of the selected localities had acquired limited  
the availability of medical 
medical equipment for a pandemic, but only  
equipment may be 
three of the five States had electronic systems  
insufficient.  To address 
to track beds and equipment  this, both PHEP and HPP 
provide States with 
funding that can be used to purchase medical equipment at the State 
and local levels.  Localities are generally responsible for storing, 
maintaining, and transporting this medical equipment.  In addition, 
HPP requires States to maintain systems that enable them to report to 
HHS the number of available hospital beds and encourages States to 
make these systems electronic.  States are also encouraged to establish 
inventory systems to track medical equipment during an emergency.    
All 10 localities had acquired limited caches of medical equipment; however, 
many experienced difficulties with managing this equipment 
As of late summer 2008, all 10 localities had acquired limited medical 
equipment to be used during a pandemic.  These caches included a variety 
of equipment, such as ventilators; portable beds; and personal protective 
equipment, such as masks, respirators, and gloves.   
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The localities used different approaches for storing this equipment.  Two 
localities distributed all of their equipment to local hospitals, whereas the 
remaining eight localities retained some equipment in regional caches and 
distributed the remainder to hospitals.  The regional caches typically 
consisted of equipment stored in trailers or public health departments.  
The equipment stored in hospitals could be used in nonemergency 
situations; however, hospitals were generally responsible for maintaining 
and replacing the equipment so that it could be redistributed in an 
emergency if needed.   
Almost all of the localities reported having difficulties with managing 
the equipment that they had acquired for a pandemic.  Many noted that 
local hospitals and health departments often did not have sufficient 
storage space.  Some localities also reported problems with maintaining 
the equipment, indicating, for example, that they were sometimes 
unsure of whether hospitals were replacing items that had expired.34  
Others mentioned difficulties with trying to standardize the medical 
equipment, such as ventilators, in their caches.  As one official noted, 
this is particularly important because standardization makes it easier 
to share equipment and it simplifies training.  Finally, a few localities 
noted that there are logistical challenges with moving equipment from 
one location to another.   
Many localities were also concerned that existing caches would be rapidly 
depleted during a pandemic.  They anticipated problems with obtaining 
equipment through normal channels during a pandemic and questioned 
whether vendors would be able to honor their contracts with an influx of 
competing orders to fill.  A few officials noted that supply chains may be 
disrupted during a pandemic, especially if the supplies are shipped from 
overseas or from another State.   
Three States had implemented electronic systems to track available hospital 
beds and medical equipment during an emergency 
Although all five States were able to meet the requirement to report 
available beds to HHS, only three States had implemented electronic 
systems to track available hospital beds during an emergency.  In 
addition to electronically tracking available beds, these systems were 
also able to track various types of medical equipment, such as 
 
34 Certain medical materials (e.g., personal protective equipment) are imprinted with an 
expiration date.  Beyond this date, the manufacturer does not guarantee the sterility, 
safety, or stability of the item. 
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respirators or masks.  The States noted that these systems simplified 
the process of collecting data from hospitals.  In addition, these systems 
enabled States to quickly disseminate information to hospitals and 
localities.  The remaining two States were in the process of developing 
such systems and noted that their current methods for collecting data 
were cumbersome. 
At the same time, most of the localities in the three States that had 
implemented electronic tracking systems reported difficulties with using 
these systems.  They noted that their State systems were not compatible 
with other systems used during an emergency.  For example, one 
locality near a State border had to input the same data into two States 
systems.  Others mentioned incompatibilities with the systems used by 
local emergency management agencies.  In addition, two localities were 
concerned about the reliability of the data.  As one noted, its State 
system may not be kept up-to-date during an emergency because 
overburdened hospital staff might not reliably enter information into 
the system. 
 
Most of the selected localities were in the early  Localities may need to use alternate 
stages of planning for alternate care sites  care sites to increase their medical 
surge capacity in a pandemic.  Before 
being able to use alternate care sites, localities need to engage in a 
significant amount of planning.  Such planning generally consists of 
identifying an appropriate location for the site; determining the scope of 
care that the site will provide in an emergency; and establishing how 
the site will be managed, staffed, and supplied.   
Nine localities had either identified or were in the process of identifying 
alternate care sites to be used in a pandemic; however, few had signed 
formal agreements  
As of late summer 2008, three localities had identified locations to be 
used as alternate care sites.  Each of the three localities had identified 
between 3 and 11 sites that could be used as alternate care sites during 
a pandemic.  The sites typically included buildings such as schools, 
churches, and convention centers.  These localities had either signed or 
were in the process of signing formal agreements with the facility 
owners.  In addition, one of these localities planned to use  
preequipped, mobile trailers that had been purchased by the State to 
supplement its alternate care sites during a pandemic.  
  OEI-02-08-00210  STATE AND LOCAL PANDEMIC INFLUENZA PREPAREDNESS:  MEDICAL SURGE  17  F I N D I N G S  
Six other localities were in the process of deciding which facilities to use 
for their alternate care sites.  The remaining locality reported that it did 
not plan to use alternate care sites at all because it was concerned that 
it would not be able to staff these sites.  Instead, its plan was for the 
hospitals in the area to take in as many patients as possible during a 
pandemic. 
None of the localities that were planning to use alternate care sites had 
plans that included the scope of care and how these sites would be 
managed, staffed, and supplied 
Of the nine localities that intended to use alternate care sites, a few 
addressed some of these components, but none addressed all of them.  
Scope of care.  Only one locality that intended to use alternate care sites 
had defined the scope of care that would be provided.  This locality 
planned to provide triage and care for only minor problems at the 
alternate care sites.  The other eight localities were still considering 
various alternatives.  In general, they explained that they would most 
likely provide triage, treatment, or both at their sites to help alleviate 
overcrowding in hospitals.  Possible treatments ranged from lower 
levels of care, such as first aid, to more intensive care or palliative care.   
Managing alternate care sites.  Three of the localities that intended to 
use alternate care sites had determined who would manage patient care 
at their sites.  These localities had arranged for the health department, 
hospitals, regional coordinating entities, or a combination of these 
entities to manage their sites.  
The other six localities were less specific about who would be 
responsible for managing patient care at the site.  One official reported 
that it is often challenging to find the appropriate people to manage an 
alternate care site; public health officials often did not have the 
specialized knowledge to manage and operate the sites, but private 
health care facilities (such as hospitals) often did not have the 
motivation.  As several officials explained, hospitals often did not want 
to participate in managing alternate care sites because of liability 
concerns, as well as staffing and reimbursement concerns. 
Staffing alternate care sites.  Only one locality had determined who 
would staff its alternate care sites.  This locality planned to use medical 
volunteers that it had already recruited and trained.  Six other localities 
that intended to use alternate care sites were still in the beginning 
stages of planning and were considering recruiting volunteers from 
groups such as the Red Cross, home health agency staff, health care 
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clinic staff, and medical school students.  The remaining two localities 
said that they would primarily rely on hospital staff.  
Supplying alternate care sites.  Four of the localities that intended to 
use alternate care sites said they had acquired some of the supplies 
needed for the sites.  These localities were planning to use the medical 
equipment from either a regional cache or a mobile trailer stocked with 
medical equipment.  In contrast, the remaining localities had not yet 
obtained supplies for the alternate care sites.  These localities were 
either planning to order the equipment during a pandemic or were in 
the process of trying to acquire equipment for the sites.   
 
During a pandemic, guidelines 
Most of the selected localities had not identified 
governing triage, admission, and 
guidelines for altering triage, admission, and 
patient care may need to be 
patient care; many cited liability concerns 
altered to save as many lives as 
possible.  To address this, 
localities may identify and adopt a standard set of guidelines for 
altering triage, admission, and patient care.  Such an approach would 
ensure that all hospitals and other health care providers in the locality 
or region were making uniform decisions during a pandemic.   
Nine localities had not identified guidelines for altering triage, admission, 
and patient care during a pandemic 
As of late summer 2008, only one locality had identified a standard set 
of guidelines for altering triage, admission, and patient care during a 
pandemic.  This locality was in the process of encouraging hospitals to 
adopt these guidelines to ensure that care was provided in a consistent 
manner.  The guidelines that this locality identified were developed in 
Canada after the Severe Acute Respiratory Syndrome outbreak.  These 
guidelines provide direction for how to alter patient care during a 
pandemic.  They also assist health care providers with determining 
whether a patient should be admitted to a hospital for treatment or 
offered other options, such as palliative care.  In particular, the 
guidelines provide hospitals with a scoring method based on specific 
characteristics of patients to use for triaging and for making decisions 
about how to equitably allocate limited resources, such as ventilators.  
Several localities highlighted the importance of coordinating the 
approaches of all hospitals and other health care providers in the 
region.  As one hospital official noted, the lack of coordination between 
admission protocols could be devastating for a local hospital.  For 
  OEI-02-08-00210  STATE AND LOCAL PANDEMIC INFLUENZA PREPAREDNESS:  MEDICAL SURGE  19  FF II NN DD II NN GG SS   
  
example, if neighboring hospitals rely on different protocols for 
admission and patient care, one hospital could become inundated with 
patients denied care at the neighboring hospital.   
Localities commonly cited concerns about liability and a lack of State or 
Federal guidance 
The nine localities that had not identified a standard set of guidelines 
gave several reasons for their reluctance.  Seven localities noted that 
providers in their localities were concerned that they would be legally at 
risk if they had to alter their triage, admission, or patient care.  As one 
locality noted, Our hospitals will functionally be practicing battlefield 
medicine.  I dont think providers are prepared to deal with this, and we 
havent even begun to deal with all the legal questions that will arise 
from practicing this type of medicine.  A few localities noted that 
instituting a uniform set of guidelines would minimize the legal risk to 
providers.   
The nine localities also reported that they wanted additional State or 
Federal guidance before attempting to institute uniform guidelines in 
their localities.  Localities were concerned that it may not be 
appropriate to institute guidelines in the absence of State or Federal 
guidance.  Several localities mentioned that it would be extremely 
valuable to have a single set of nationwide or statewide guidelines.  As 
one official noted, when you start to alter your protocols for patient 
care without the backing of statewide guidelines, you open yourself up 
to potential litigation.  
 
Localities conduct exercises to test 
All of the selected localities conducted medical     
and improve their preparedness 
surge exercises; however, none consistently 
efforts.  HPP and PHEP guidance 
documented the lessons learned
require States to conduct exercises 
and encourage States to conduct these exercises pursuant to HSEEP 
requirements.35  Among other things, HSEEP requires participants to 
create an after-action report that documents the preparedness issues 
that arose during the exercise and an improvement plan that shows how 
participants will follow up on the lessons learned. 
 
35 Beginning in August 2008, all exercises associated with HPP and PHEP funding were 
required to meet HSEEP requirements for after-action reports and improvement plans.  
Note that this was not a requirement for any of the exercises reviewed for this study. 
  OEI-02-08-00210  STATE AND LOCAL PANDEMIC INFLUENZA PREPAREDNESS:  MEDICAL SURGE  20  F I N D I N G S  
 
Localities conducted between one and seven medical surge exercises over 
a 2-year period  
Between mid-2006 and mid-2008, the 10 selected localities conducted a 
total of 41 exercises that focused on medical surge.  Over half of these 
exercises were specific to a pandemic, whereas the remainder focused on 
other types of emergencies.  As shown in Figure 1, the exercises most 
commonly focused on coordination among hospitals and other 
responders, followed by the management of medical equipment.  Fewer 
exercises tested the use of alternate care sites; guidelines for altering 
triage, admission, and patient care; and volunteers.  Most exercises 
focused on more than one medical surge component. 
Figure 1:  39
40
Number of  37
Exercises by 
Medical Surge 
Component  es 30
s
ci
r
xe 21 20
E
of  20 17
r 
e
b
m
u
N 10
0
Coordination Medical Alternate Triage, Volunteers
Equipment Care Sites Admission,
Patient Care
Source:  OIG analysis of documentation from selected States and localities, 2009. 
Note:  Most exercises focused on more than one medical surge component. 
Most of the medical surge exercises were discussion based, rather than 
operations based  
Discussion-based exercises can be used to identify and address gaps 
in preparedness plans before more resource-intensive operations-
based exercises are conducted.  As shown in Table 1, over half of the  
41 medical surge exercises conducted by the 10 selected localities 
were discussion based and over a third were operations based.  The 
remaining exercises were actual emergencies that localities evaluated 
for lessons learned.  In total, 7 of the 10 localities conducted at least 
one discussion-based exercise and one operations-based exercise.   
 
  OEI-02-08-00210  STATE AND LOCAL PANDEMIC INFLUENZA PREPAREDNESS:  MEDICAL SURGE  21  F I N D I N G S  
 
Table 1:  Number of Exercises, by Type of Exercise  
Number of  Percentage 
Type of Exercise 
Exercises  of Exercises 
Discussion-based   23  56% 
Operations-based   15  37% 
Based on Actual Emergencies  3  7% 
    Total  41  100% 
 
Source:  OIG analysis of documentation from selected States and localities, 2009. 
Localities discussion-based exercises typically involved discussions by 
participants regarding potential responses to simulated scenarios in an 
informal setting.  These types of exercises most commonly involved a 
facilitator who described a mock emergency to the participants.  During 
each phase of the mock emergencyhour-by-hour or week-by-weekthe 
participants discussed how they would respond.  Typically, the 
facilitator prompted the participants with predetermined questions.  
For example, as part of one localitys exercise, the facilitator described a 
scenario, stating that It is now three hours into the incident.  You are 
at capacity for beds.  Your staffing is at 83 percent of your 
requirements . . . .  The facilitator then posed a variety of questions to 
participants, such as:  What are your top five priorities now?; What 
are your alternate care site plans?; and What do you need to do with 
regard to medical supplies? 
In contrast, localities operations-based exercises typically occurred in 
participants actual work environments and participants physically 
responded to a mock emergency.  For example, in one exercise, the 
following events were communicated to participants in hospitals via 
radio:  Local Emergency Operations Centers requesting update on 
hospital status by 9 a.m. and Some hospitals are reporting influx of  
people . . . .  Participants then had to respond and provide their status.  
Some of the operations-based exercises also involved the actual delivery 
of equipment and supplies or an influx of mock patients to hospitals. 
In addition, three localities experienced actual emergencies that they 
evaluated for lessons learned.  For example, one locality evaluated its 
medical surge response to an ice storm in which staff at local hospitals, 
the public health department, the Red Cross, and emergency 
management coordinated to establish and run shelters for 400 residents 
  OEI-02-08-00210  STATE AND LOCAL PANDEMIC INFLUENZA PREPAREDNESS:  MEDICAL SURGE  22  F I N D I N G S  
 
over 10 days.  Another locality evaluated how it responded to a local 
shooting in which numerous people were admitted to the hospital.   
Localities did not consistently document the lessons learned from 
exercises  
As noted earlier, localities are encouraged to document lessons learned 
during exercises through the creation of after-action reports and 
improvement plans.  None of the 10 localities had completed an  
after-action report and an improvement plan for all of their exercises.  
However, all of the localities had completed either an after-action report 
or an improvement plan for at least one of their exercises. 
For 9 of the 41 exercises, localities completed neither after-action 
reports nor improvement plans.  For another 20 exercises, localities  
completed only after-action reports.  For the remaining 12 exercises, 
they completed both after-action reports and improvement plans.  See 
Figure 2.      
 
After-Action Report and  No After-Action Report and 
Figure 2: 
Improvement Plan No Improvement Plan
Number of 
(12 Exercises; 29%) (9 Exercises; 22%)
Exercises With 
After-Action 
Reports and 
Improvement Plans 
After-Action Report Only
(20 Exercises; 49%)
  Source:  OIG analysis of documentation from selected States and localities, 2009. 
Localities reported several problems with preparing after-action reports 
and improvement plans.  Specifically, they mentioned difficulties with 
conforming to HSEEP requirements that specify the format of and type 
of information that needs to be included in after-action reports and 
improvement plans.  One locality reported that these requirements were 
not hospital-friendly, while another locality reported needing a  
full-time person to complete all of the required documents. 
  OEI-02-08-00210  STATE AND LOCAL PANDEMIC INFLUENZA PREPAREDNESS:  MEDICAL SURGE  23  F I N D I N G S  
 
Exercises showed that localities needed to make improvements within the 
five medical surge components  
The after-action reports from the exercises we reviewed showed that 
localities needed to make improvements within the five medical surge 
components.  In particular, several reports highlighted the need for 
better coordination among stakeholders as well as the need for a better 
understanding of their roles and responsibilities during an emergency.  
Other reports focused on the need to improve coordination with 
emergency management agencies as well as enhance coordination with 
health care entities, such as long term care facilities and clinics.   
After-action reports also highlighted difficulties with medical 
equipment.  Several reports indicated that localities had not assessed 
their equipment needs or could not deploy existing equipment.  These 
reports also indicated that hospitals did not have plans for dealing with 
equipment shortages.  One report pointed out that the locality had not 
established agreements among its hospitals to help facilitate the 
sharing of equipment.   
A few after-action reports also showed a need for localities to make 
improvements within the other medical surge components.  These 
reports cited a need for localities to start or continue to plan for 
alternate care sites, specifically in terms of establishing who would 
manage and staff the sites.  For example, one report noted that local 
hospitals and the public health department disagreed over who would 
open alternate care sites.  Several reports also showed the need for 
localities to recruit additional medical volunteers, such as medical and 
nursing students.  Another report noted that the locality should 
consider developing guidelines for altering patient care and determine 
the legality of adopting these guidelines.   
 
 
  OEI-02-08-00210  STATE AND LOCAL PANDEMIC INFLUENZA PREPAREDNESS:  MEDICAL SURGE  24   R E C O M M E N D A T I O N S  
 
The recent public health emergency caused by an outbreak of human 
cases of H1N1 influenza has highlighted the need for States and 
localities to be prepared for a medical surge.  Our review found that 
although the selected States and localities are making progress within 
the five components of medical surge that we reviewed, more needs to 
be done to improve States and localities ability to respond to a 
pandemic.   
Specifically, we found that in preparation for a pandemic, all of the  
10 selected localities had established partnerships to prepare for a 
medical surge; however, the degree to which this coordination occurred 
varied.  We also found that fewer than half of the selected localities had 
started to recruit medical volunteers, and none of the five States had 
implemented an electronic system to manage these volunteers.  
Similarly, all selected localities had acquired limited medical equipment 
for a pandemic, but only three of the five States had electronic systems 
to track available beds and equipment.  In addition, most of the selected 
localities were in the early stages of planning for alternate care sites, 
and most localities had not identified guidelines for altering triage, 
admission, and patient care during a pandemic.  Finally, although all of 
the selected localities conducted medical surge exercises, none 
consistently documented the lessons learned.    
Based on these findings, we recommend that ASPR, in collaboration 
with CDC:   
Work with States and localities to improve their efforts within each 
of the five components of medical surge that we reviewed  
  ASPR should continue to emphasize the importance of coordination and 
involving a wide array of stakeholders in medical surge and pandemic 
planning.  Specifically, additional guidance should focus on integrating 
local hospitals into emergency response planning as well as 
emphasizing the importance of including other health care providers
such as nursing homes, home health agencies, clinics, and physicians
in pandemic planning efforts.  In addition, ASPR should collaborate 
with CDC to ensure that public health officials are actively involved in 
medical surge preparedness activities.  
  ASPR should continue to emphasize the importance of recruiting, 
registering, and training medical volunteers for use in a pandemic.  In 
addition, ASPR should continue to monitor States progress in 
developing electronic systems (pursuant to the guidelines established 
  OEI-02-08-00210  STATE AND LOCAL PANDEMIC INFLUENZA PREPAREDNESS:  MEDICAL SURGE  25  R E C O M M E N D A T I O N S  
for ESAR-VHP) to register volunteers and verify credentials.  ASPR 
should also encourage States and localities to make use of existing 
Federal volunteer programs, such as the Medical Reserve Corps. 
  ASPR should continue to emphasize the importance of managing 
medical equipment currently being stockpiled for a public health 
emergency, such as a pandemic.  Specifically, ASPR should consider 
providing guidance on how best to store, maintain, and transport 
medical equipment.  In addition, ASPR should consider providing 
guidance on the tracking of medical equipment in addition to the 
tracking of available hospital beds.   
  ASPR should continue to emphasize the importance of planning for 
alternate care sites for use during a pandemic.  ASPR should include 
specific guidance about determining the scope of care to be provided at 
alternate care sites and how the sites can be managed, staffed, and 
supplied.   
  ASPR should emphasize the importance of identifying and adopting 
guidelines for altering triage, admission, and patient care during a 
pandemic.  ASPR should consider developing guidelines for altering 
standards of care during a pandemic.  These guidelines could serve as 
a model for States.  In addition, ASPR should strengthen current 
guidance to encourage hospitals and other health care providers to 
make uniform decisions during a pandemic. 
Ensure that States and localities consistently document the lessons 
learned from preparedness exercises that address medical surge 
Given the importance of exercises in strengthening preparedness, 
ASPR, in collaboration with CDC, should ensure that States and 
localities consistently document the lessons learned from all medical 
surge exercises that require HSEEP compliance.  ASPR and CDC 
should conduct additional reviews to ensure that such exercises are 
meeting HSEEP requirements.   
Address the issue of legal protections for medical professionals and 
volunteers who respond to public health emergencies, such as an 
influenza pandemic 
ASPR should consider working with States to develop appropriate legal 
protections for medical professionals and volunteers who respond to public 
health emergencies, such as an influenza pandemic, and who may need to 
alter standards of care.  ASPR should also consider the feasibility of 
Federal legislation in this area.  Additionally, ASPR should encourage 
States and localities to inform health care providers about liability issues 
  OEI-02-08-00210  STATE AND LOCAL PANDEMIC INFLUENZA PREPAREDNESS:  MEDICAL SURGE  26  R E C O M M E N D A T I O N S  
using documents such as AHLAs Community Pan-Flu Preparedness:  A 
Checklist of Key Legal Issues for Healthcare Providers. 
Facilitate the sharing of information and emerging practices 
among States and localities  
ASPR, in collaboration with CDC, should collect information on 
emerging practices from States and localities, as well as experts in the 
field, to further improve medical surge preparedness.  These efforts 
should focus particularly on planning for alternate care sites and 
identifying and adopting guidelines for altered standards of care.  ASPR 
should employ a variety of strategies to facilitate the sharing of 
information and emerging practices among States and localities.  For 
example, ASPR could develop a secure Web site or listserv where States 
and localities could compare themselves to other States and localities 
with similar characteristics and share information.  ASPR could also 
provide a mentoring program for State officials responsible for 
preparedness as well as develop additional opportunities for in-person 
meetings.   
Provide training and technical assistance to States and localities on 
key issues 
ASPR, in collaboration with CDC, should provide training and technical 
assistance to States and localities to bolster their medical surge 
preparedness efforts.  ASPR should address specific State and local 
challenges, such as identifying alternate care sites, managing medical 
equipment, and identifying guidelines for alternate standards of care.  
ASPR should use its partnerships with existing groups, such as the 
National Association of County and City Health Officials, the 
Association of State and Territorial Health Officials, and the American 
Hospital Association, to help facilitate these activities.   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
ASPR concurred with all five of our recommendations.  The full text of 
ASPRs comments is provided in Appendix B.  CDC did not formally 
comment, but did provide technical comments.  We made changes to the 
final report based on CDCs technical comments, as appropriate.   
 
  OEI-02-08-00210  STATE AND LOCAL PANDEMIC INFLUENZA PREPAREDNESS:  MEDICAL SURGE  27    A P P E N D I X ~ A
 
 
Selected States and Localities 
 
State  Locality  
Maine  Portland 
Lewiston 
Missouri  Saint Louis 
Rolla 
South Dakota   Sioux Falls 
Mitchell 
Virginia  Virginia Beach 
Blacksburg 
Washington  Seattle 
Longview 
 
  OEI-02-08-00210   STATE AND  LOCAL  PANDEMIC  INFLUENZA  PREPAREDNESS:   MEDICAL  SURGE   28  ..
A P PEN D
x
B
Agency Comments
(~
l'if,IIVIc,
DEPARTMNT OF HEALTH & HUAN SERVICES Offce of the Seretary
~.,'~~
Assistant Secretary for
Prepa'Iness & Response
Washlnglon. 0.0.20201
DA'ff: September 1, 2009
TO: Stuar Wright
Deputy Inpector General for Evaluation  and Inspections
FROM: Gerald W. Parker, DVM, PhD, MS
Principal Deputy Assistat Secreta for Preparedness  and  Response
SUBJECT: OIG Draft Report: "State and LocalPandemic InfuenZ Preparedness: Medical
Surge," OEI-02-08-0021 0
The Offce of  the Assistat Secreta for Preparedness and  Response (ASPR) appreciates the
opportty to review and respond to the Offce ofInspector Geneta's (OIG) dr report
entitled, "State and  Local Pandemic Infuenza Praredness: Medical Surge," OEI-02-08-00210.
om Recomiuendations
. Work with States and localiies to improve tbeir efforts within each oftbe five
components of medical surge tbat we reviewed.
o ASPR should continue to emphasize the importance of coordination and involving a wide
aray of steholders in medical surge and pandemic plan.
recruiting, registering, and
o ASPR should continue to emphasize the importce of 
traing medical volunteers for use in a pandemic.
of manging medical equipment
o A8PR should contiue to emphaize the importce 
curently being stockpiled for a public  health emergency such as a pandemic.
planng for alternate care sites
o ASPR should continue  to emphaize  the importce of 
for use durg a pandemic.
o ASPR should emphasize the importce of identifYing and  adopting gudelines for
a pandemc.
alterig triage, admission, and patient care during 
lessons learned from
. Ensure that states and localitiescbnsistentlydocuiuent the 
preparedness exercises that address medicalsurge.
. Address the issue onegal protections foriuedical profllsionals andVblunteers wbo
respond to public health eiuergencies, such as an influenza pandemic.
. ASPR sbould consider working witbStates to faciltate the sharing of information and
emerging  practices among States and localities.
. Provide training and technical assistance to States and localities on key issues.
ASPR Resllonse
We concur with  these recomiendationsand look forward to working with  the OIG on this issue.
OEI.02.08.00210 STATE AND LOCAL PANDEMIC INFLUENZA PREPAREDNESS: MEDICAL SURGE 29  A C K N O W L E D G M E N T S  
This report was prepared under the direction of Jodi Nudelman, 
Regional Inspector General for Evaluation and Inspections in the  
New York regional office, and Meridith Seife, Deputy Regional Inspector 
General.   
Judy Kellis served as the team leader for this study.  Other principal 
Office of Evaluation and Inspections staff from the New York regional 
office who contributed to the report include Judy Bartlett and  
Christine Moundas; central office staff who contributed include  
Talisha Searcy and Robert Gibbons.  
 
 
  OEI-02-08-00210  STATE AND LOCAL PANDEMIC INFLUENZA PREPAREDNESS:  MEDICAL SURGE  30