The Agency for Healthcare Research

and Quality (AHRQ) is the lead agency

charged with supporting research

designed to improve the quality of

health care, reduce its cost, address

patient safety and medical errors, and

broaden access to essential services.

AHRQ sponsors and conducts research

that provides evidence-based

information on health care outcomes;

quality; and cost, use, and access. 

The information helps health care

decisionmakers—patients and 

clinicians, health system leaders, and

policymakers—make more informed

decisions and improve the quality of

health care services.

Bioterrorism

and Health System Preparedness

Issue Brief

Developing Alternative Approaches

to Mass Casualty Care:

The Role of the Agency for

Healthcare Research and Quality

No. 11

A bioterrorist attack, a naturally occurring

disease outbreak, or some other 

large-scale public health emergency all

have the potential to result in enough

casualties to overwhelm patient care

resources. In response to that threat,

health care organizations and systems at

the local, regional, State, and Federal

levels have taken steps to develop surge

capacity, which is defined by the U.S.

Department of Health and Human

Services (HHS) as “a health care system’s

ability to expand quickly beyond normal

services to meet an increased demand for

medical care.” Within HHS, the Agency

for Healthcare Research and Quality has

been assigned responsibility for

developing and assessing alternative

approaches to ensuring health care surge

capacity for mass casualty events. 

Background

HHS has developed a Department-wide

strategic plan to delineate priorities and

assign responsibilities for bioterrorism

preparedness. The Office of the Assistant

Secretary for Public Health and

Emergency Preparedness (OASPHEP) is

responsible for coordinating and directing

the Department’s emergency preparedness

and response programs, including

antibioterrorism efforts. The HHS

agencies with the most national visibility

in bioterrorism preparedness are the

Centers for Disease Control and

Prevention (CDC) and the Health

Resources and Services Administration

(HRSA). The National Institutes of Health

and the Food and Drug Administration

also play key roles.

Advancing Excellence in Health Care www.ahrq.gov

Agency for Healthcare Research and Quality

Surge capacity is “a health

care system’s ability to

expand quickly beyond

normal services to meet an

increased demand for

medical care.”
The Agency for Healthcare Research

and Quality (AHRQ) has been

working steadily since 2000 to sponsor

research that provides the evidence

base for tools and resources needed for

bioterrorism planning and response.

AHRQ has funded more than 50

research projects, workshops, and Web

conferences. Based on HHS priorities,

AHRQ-sponsored research in 2004

focused on health system preparedness

for surge capacity and in 2005 focused

on mass casualty care. This Issue

Brief reviews AHRQ’s research on

mass casualty care.

Planning

Health system preparedness for mass

casualty care requires exceptional

planning and coordination among

health systems at the local, State, and

regional levels. The projects described

here are major contributions to that

effort.

The Rocky Mountain

Regional Care Model for

Bioterrorist Events 

This model was developed under a

contract with Denver Health and its

partners in AHRQ’s Integrated

Delivery System Research Network

(IDSRN). The model was developed

specifically for Federal Region VIII

(Colorado, Utah, Wyoming, Montana,

North Dakota, and South Dakota), but

can be used by other States as well.

The report is available on the AHRQ

Web site at

http://www.ahrq.gov/research/altsites.ht

m. Key parts of the report have been

modified to be used as examples by

other regional, State, and local public

health agencies. Those tools are

available on the Denver Health Web

site at

www.denverhealth.org/bioterror/Tools.

htm. 

Profile of Regional Medical Resources

is a comprehensive inventory of the

medical resources available in the

region. Included are medical care

facilities (number, type, location, and

total physical beds of hospitals in the

region); medical care providers

(physicians, physician assistants, nurse

practitioners, registered nurses,

licensed practical nurses, and

respiratory therapists); and hospital

resources and infrastructure (including

personal protective equipment,

negative airflow isolation rooms,

isolation beds, and decontamination

capability). The tool provides an

example of a methodology and

includes citation of resources that are

available to all States. 

Supply and Staffing Options for an

Alternative Care Site is predicated on

the assumption that situations

involving mass casualties will require

either augmentation to a hospital’s

patient medical resource capacity or

establishment of an alternative site for

care. Lists for three levels of supplies

are provided: a hospital augmentation

cache (50-bed unit); a regional

alternative site cache of medical

supplies for a 500-bed unit; and a

comprehensive cache, including

equipment and supply lists, for a 50-

bed alternative care site. A table on

staffing requirements for a 50-bed

alternative care site provides the

minimum number of staff required per

12-hour shift for three types of events:

infectious, noninfectious, and

quarantine. 

Two other resources are appended to

the Supply and Staffing tool. One

addresses oxygen supply options. A

supply of oxygen is critical if the agent

involved affects the respiratory tract

(e.g., smallpox, anthrax, pneumonic

plague, hemorrhagic fevers, ricin). Any

possible solution to a deployable

oxygen supply, however, is both

complex and costly. This appendix

presents the issues that must be

addressed. The second appendix is a

collection of draft gubernatorial orders

that were developed by the Colorado

Department of Public Health and

Environment to address health care

licensing and other legal issues that

would arise in the event of a mass

casualty situation. 

To provide a tool that can

quantitatively predict the best choice

for an alternative care site, the Denver

Health project developed the

Alternative Care Site Selection Matrix.

This tool is available in a Web version

and an Excel spreadsheet. The Matrix

helps identify the strengths and

weaknesses of possible alternative care

sites (such as a school, stadium,

recreation center, or armory) in a

geographic area.

The fourth tool, Regional Measures of

Preparedness, takes data collected

using the Profile of Regional Medical

Resources and the Supply and Staffing

tools and compares them with

established benchmarks created by

HRSA and others. Measures of

preparedness include additional

hospital beds, medical staff,

equipment, and infrastructure. The tool

provides examples of measures and the

methodology for developing them that

can be replicated by other States and

regions. 

Models for Emergency

Preparedness: Personal

Protective Equipment,

Decontamination,

Isolation/Quarantine, and

Laboratory Capacity

Planning for response to a bioterrorism

event or other public health emergency

2
must include the equipment and

facilities to accommodate the surge in

patient loads. Science Applications

International Corporation (SAIC)

developed models for personal

protective equipment, decontamination,

isolation/quarantine, and laboratory

capacity to serve as evidence-based

user tools for operational planning

based on best-demonstrated practices.

Development of each model took into

consideration factors such as: 

▲ adaptability for use in different

regions of the country and in

different settings (e.g., urban vs.

rural);

▲ cost, including supplies, logistics,

and training;

▲ level of training required; 

▲ resources required, including

whether the model could be built

using existing practices and

infrastructure; 

▲ impact on morbidity and mortality;

and 

▲ regulatory compliance. 

This report is available on the AHRQ

Web site at

http://www.ahrq.gov/research/devmodel

s/. A common thread in the findings is

the importance of the community in

emergency preparedness. The

preparedness plan should be tailored to

the community, be communicated to

the community, and involve both the

health system and emergency providers. 

Building Blocks for Mass

Prophylaxis

One of the first projects funded by

AHRQ in 2000 was the development

by Weill Medical College of Cornell

University of a computer simulation

model for planning a citywide response

to a bioterrorist attack. Four additional

products funded by AHRQ have grown

or are growing out of that original

model:

▲ Community-Based Mass

Prophylaxis: A Planning Guide for

Public Health Preparedness

(http://www.ahrq.gov/research/cbmp

rophyl/cbmpro.htm) explains in

detail the components a community

must have in place to prepare for

mass prophylaxis. 

▲ Bioterrorism and Epidemic

Outbreak Response Model (BERM)

(http://www.ahrq.gov/research/biom

odel.htm), a companion tool to the

Planning Guide, is an interactive

database that allows planners to

calculate the numbers of facilities

and staff they will need in their

communities to administer mass

prophylaxis. 

▲ The Regional Hospital Caseload

Calculator (in process) starts with

the community’s capability to

administer mass prophylaxis and

computes the number of people

who can be reached daily with

prophylaxis and the number who

will become ill and require

hospitalization. 

▲ Modeling U.S. Health System’s

Epidemic Response Capacity (in

process) will start with the

capability to administer mass

prophylaxis, add local hospital bed

capacity, and calculate pre-hospital

response, hospital-based response,

and the need for assistance from

outside the region. 

Taken together, these four tools

constitute building blocks for

community preparedness for mass

prophylaxis.

Pediatric Preparedness for

Disasters and Terrorism: A

National Consensus

Conference and Executive

Summary

One concern of health system

preparedness for surge capacity is

providing care for special populations.

AHRQ has taken a lead role in funding

research for pediatric preparedness.

Children comprise approximately 25

percent of the U.S. population, and

more than 20 million of them are under

the age of six. Thus, children should be

included in any jurisdiction’s

preparedness plan.

The specific elements of pediatric

preparedness were developed at a

conference in February 2003 that was

funded by AHRQ, the Emergency

Medical Services for Children Program

in HRSA’s Maternal and Child Health

Bureau, and the Phoenix Foundation.

The Execuitve Summary from Pediatric

Preparedness for Disasters and

Terrorism: National Consensus

Conference provides the first and only

set of pediatric emergency preparedness

guidelines and treatment

recommendations. The report also

includes guidance for pre-hospital and

hospital care, recommendations on

3

The preparedness plan

should be tailored to the

community, be

communicated to the

community, and involve both

the health system and

emergency providers. 

AHRQ has taken a lead role

in funding research for

pediatric preparedness.
training, and specific guidance

regarding numbers of equipment,

numbers of providers, actual dosages,

and treatment protocols across the

range of possible disasters, terrorism,

and other public health emergencies.

The conference’s executive summary

can be found on the CDC Web site at

http://www.bt.cdc.gov/children/pdf/

working/execsumm03.pdf. 

Reopening Shuttered

Hospitals to Expand Surge

Capacity

Researchers at Abt Associates and

Partners Healthcare (Brigham and

Women’s Hospital and Massachusetts

General Hospital) have developed a

guidebook on the possible conversion

of former inpatient hospitals into

temporary facilities for low-acuity

patients during a mass casualty event. 

The report examines what closed

and/or converted hospitals could

potentially contribute in an

emergency; and what would need to

be done in advance to prepare to

rapidly expand a hospital’s surge

capacity. Regulatory requirements and

barriers are explored in an extensive

appendix.

The report is accompanied by a Surge

Tool Kit and a Facility Checklist for

use in evaluating specific hospitals. 

Training

Training has been one of AHRQ’s

priorities since the beginning of its

bioterrorism preparedness program.

Two projects relevant to training for

mass casualty care are described here.

Bioterrorism and Emerging

Infections Web Site

Development of this Web site at the

University of Alabama at

Birmingham was one of the first

projects funded by AHRQ in 2000.

The site offers nine online continuing

education case-based modules and

free continuing medical education

(CME) credit. The tool helps users

identify potential bioterrorist

microorganisms, and common

syndromes associated with emerging

infectious diseases or bioterrorist

agents and recognize an outbreak

resulting from bioterrorism or from

rare infectious diseases. The

Bioterrorism and Emerging Infections

Web site is available at

http://www.bioterrorism.uab.edu/.

Evaluation of Hospital

Disaster Drills:A ModuleBased Approach 

A critical focus for hospital disaster

planning has been the use of drills to

train employees in and to test aspects

of hospital response. The evaluation

modules provided by this tool,

available at http://www.ahrq.gov/

research/hospdrills/hospdrill.htm and

designed by the Johns Hopkins

University Evidence-based Practice

Center, make it possible for planners

to identify specific weaknesses for

improvement and promote continuing

efforts to strengthen hospital disaster

preparedness. Modules cover topics

such as incident command,

decontamination, triage, and treatment

A module on training provides

guidance on objectives, drill

preparation, evaluator training, and

other relevant issues. Pre-drill and

debriefing sections are also provided. 

Response

AHRQ has also funded the

development of tools to facilitate

response capability in a mass casualty

incident.

Emergency Preparedness

Resource Inventory (EPRI)

This Web-based tool developed by

Abt Associates can be used to

assemble an inventory of critical

resources for response to bioterrorism

and other emergencies. EPRI is

intended to store and routinely update

information from diverse service

providers and responders in a region,

especially a rural region, for both

planning and incident response.

Information includes available

equipment, personnel, and supplies.

The tool allows the host/administrator

to specify what types of organizations

to include, what types of resources,

how often to update, who has access

to various levels of inventory reports,

and other parameters. 

Use of the application requires a

high-speed connection and a secure

Web page to ensure confidentiality of

the data. In addition to the software

tool, the application includes an

implementation report that explains

the concepts and operation of the tool

and describes lessons learned from

the pilot test in an eight-county region

in rural Pennsylvania. A technical

manual summarizes the installation

process and system functions.

Planners can use the tool to determine

the variety of resources available in

the region and to identify gaps in

those resources. Incident response

managers can use the tool to deploy

resources in response to a particular

incident. The tool and accompanying

supporting documents are available

on the AHRQ Web site at

http://www.ahrq.gov/research/epri/. 

4
Health Emergency Assistance

Line and Triage Hub

(HEALTH) Model

One of the key components of surge

response is risk and crisis

communication: informing the public

of an emergency and of resources

available to help them. Good

communication reduces the number of

“worried well”— people presenting to

health care facilities who may not need

to be seen. This allows hospital

resources to be used more effectively to

treat those who need them the most.

The HEALTH Model report describes

how the Denver Health Medical

Information Centers determined the

requirements, specifications, and

resources needed to develop a public

health emergency contact center that is

integrated with public health agencies. 

The HEALTH Contact Center

Assessment Tool assists agencies in

developing the capabilities and

functions of the HEALTH Model. This

workbook contains step-by-step

instructions for completing five

component parts: 

▲ Contact Surge Calculator—

Provides a simple way to predict the

volume of contacts (phone, Web

site, e-mail, fax) that may be

expected by a public health agency

in a public health emergency.

▲ Staffing/Resource Calculator—

Provides a simple way to determine

personnel needed to handle a given

number of contacts, based on

industry standards. This tool will

help agencies understand staffing

and basic resource requirements for

an internal contact center or hotline.

▲ Capital & Technology Expense

Calculators—Help assess the

facilities, technology, and

equipment needed to handle a given

number of contacts. These tools

calculate the potential capital

needed for resources not currently

available and help agencies

understand potential costs

associated with an internal contact

center or hotline.

▲ Surge Options Matrix—Provides a

way to assess an agency’s

capabilities for implementing an

emergency contact center or hotline

and suggests options.

The report and tool are available on the

AHRQ Web site at

http://www.ahrq.gov/research/health/. 

National Hospital Available

Beds for Emergencies and

Disasters (HAvBED) System

The National Hospital Available Beds

for Emergencies and Disasters

(HAvBED) System explores the

feasibility of a national real-time

hospital-bed tracking system to address

a surge of patients during a mass

casualty event. The model is an

exportable system that allows Federal,

regional, or State command centers to

access standardized information across

the entire Nation. 

The model, developed by Denver

Health and tested during the summer of

2005, is described and evaluated in a

report at http://www.ahrq.gov/research/

havbed/. The model collected and

integrated data from existing reporting

systems and from hospitals outside

those systems that entered data via a

secure Web site. 

The report includes:

▲ A discussion of the components of

the HAvBED System, including the

communications protocol, database,

and Geographic Information

System. 

▲ A virtual tour of the system. 

▲ Standardized hospital bed

definitions to provide uniform

terminology for organizations

tracking bed availability. 

▲ Reviews of existing bed-tracking

systems. 

▲ Conceptual and technical

recommendations. 

The results in this report currently are

being reviewed by Federal agencies and

others to determine next steps in

making the model operational.

Altered Standards of Care in

Mass Casualty Events

Altered Standards of Care in Mass

Casualty Events is the product of a

2004 meeting by AHRQ and

OASPHEP. In that meeting, experts in

the fields of bioethics, emergency

medicine, emergency management,

health administration, health law and

policy, and public health addressed the

possibility that a mass casualty event

could compromise the ability of health

systems to deliver services consistent

with established standards of care. The

full report is available on the AHRQ

Web site at http://www.ahrq.gov/

research/altstand/. The report’s

recommended action steps for planning

and implementing health care during a

mass casualty event provide a potential

framework for future research: 

▲ Develop general and event-specific

guidance for allocating scarce

health and medical care resources.

▲ Develop and implement a process

to address non-clinical issues

related to the delivery of health and

medical care.

▲ Develop a comprehensive strategy

for risk communication with the

public.

5
6

▲ Identify, analyze, and consider

modification of Federal, State, and

local laws and regulations that may

affect the delivery of health and

medical care.

▲ Develop a means for verifying

credentials of medical and other

health personnel in advance and on

site.

▲ Create strategies to ensure health

and medical leadership and

coordination for the health and

medical aspects of system

response.

▲ Continue and expand efforts to

train providers and others to

respond effectively.

▲ Develop and support a research

agenda specific to health and

medical care standards.

▲ Develop a Community-Based

Planning Guide for Mass Casualty

Care.

▲ Identify and support States, health

systems, and regions to develop

mass casualty and health and

medical care response plans based

on the Planning Guide and to share

their results widely. 

Web Conferences and

Issue Briefs

AHRQ has sponsored a series of Web

conferences focused on surge capacity

and mass casualty care. Each Web

conference includes presentations by

AHRQ grantees and contractors who

summarize projects in progress or

recently completed. Other

presentations are made by

representatives of other Federal, State,

and local government agencies and

grantees involved in preparations for

surge capacity and mass casualty care. 

The conferences are available as

streaming presentations and transcripts

with presenter slides on the AHRQ

Web site at

http://www.ahrq.gov/browse/

bioterbr.htm. They also are

summarized as Issue Briefs, available

on the site. 

This Issue Brief was prepared for

AHRQ by the National Academy for

State Health Policy (NASHP) under

contract number 290-98-0009.

AHRQ Pub. No. 06-0073

September 2006

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