Number 364 + September 27, 2005

Bioterrorism and Mass Casualty Preparedness in

Hospitals: United States, 2003

by Richard W. Niska, M.D., M.P.H., and Catharine W. Burt, Ed.D., Division of Health Care Statistics

Abstract

Objectives—This study examined the content of hospital terrorism preparedness

emergency response plans; whether those plans had been updated since September

11, 2001; collaboration of hospitals with outside organizations; clinician training in

the management of biological, chemical, explosive, and nuclear exposures; drills on

the response plans; and equipment and bed capacity.

Methods—The National Hospital Ambulatory Medical Care Survey (NHAMCS)

is an annual survey of a probability sample of approximately 500 non-Federal

general and short-stay hospitals in the United States. A Bioterrorism and Mass

Casualty Supplement was included in the 2003 survey and provided the data for this

analysis.

Results—Almost all hospitals have plans for responding to natural disasters

(97.3 percent). Most have plans for responding to chemical (85.5 percent), biological

(84.8 percent), nuclear or radiological (77.2 percent), and explosive incidents

(76.9 percent). About three-quarters of hospitals were integrated into communitywide disaster plans (76.4 percent), and 75.9 percent specifically reported a

cooperative planning process with other local health care facilities. Despite these

plans, only 46.1 percent reported written memoranda of understanding with these

facilities to accept inpatients during a declared disaster. Hospitals varied widely in

their plans for re-arranging schedules and space in the event of a disaster. Training

for hospital incident command and smallpox, anthrax, chemical, and radiological

exposures was ahead of training for other infectious diseases. The percentage of

hospitals training their staff in any exposure varied from 92.1 percent for nurses to

49.2 percent for medical residents. Drills for natural disasters occurred more often

than those for chemical, biological, explosive, nuclear, and epidemic incidents.

More hospitals staged drills for biological attacks than for severe epidemics. Despite

explosions being the most common form of terrorism, drills for these were staged

by only one-fifth of hospitals. Hospitals collaborated on drills most often with

emergency medical services, fire departments, and law enforcement agencies.

Keywords: bioterrorism c emergency response plans c medical training c mass

casualty drills c medical equipment

Introduction

In response to the terrorism

incidents of September 2001, the Office

of the Assistant Secretary of Planning

and Evaluation, Department of Health

and Human Services, requested that the

Centers for Disease Control and

Prevention’s (CDC) National Center for

Health Statistics (NCHS) survey

hospitals regarding their preparedness

for treating patients from bioterrorism

attacks or mass casualty incidents. It

provided funding to field a special

supplement to the 2003 National

Hospital Ambulatory Medical Care

Survey (NHAMCS).

Data from the 2003 NHAMCS

supplement will serve as a baseline for

hospital terrorism preparedness because

there were no major funding programs

directed toward hospitals for this

purpose prior to the start of the

Bioterrorism Hospital Preparedness

Program of the Health Resources and

Services Administration (HRSA) in

fiscal year (FY) 2002. Even these funds

had not yet been fully awarded to

hospitals at the time this survey was

fielded in 2003 (1,2). Prior to the

inception of the HRSA program, the

Domestic Preparedness Program of the

Department of Defense had not

allocated any funding for hospitals,

although it funded emergency response

agencies (3).

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Disease Control and Prevention 

National Center for Health Statistics 
2 Advance Data No. 364 + September 27, 2005

Because the NHAMCS terrorism

supplement was also repeated in 2004, it

will be possible to study changes in

preparedness as a function of the

funding made available through major

Federal programs. Information about

strengths and limitations of terrorism

preparedness in the Nation’s hospitals

will be crucial for appropriate Federal

agencies that are charged with planning

how future funding should be used to

improve domestic defensive posture.

Hospitals would be among the first

institutions affected after deployment of

a weapon of mass destruction. They

would treat those injured in terrorist

attacks in ways not unlike those used

for other incidents where large numbers

of patients are involved. After a

biological attack, emergency

departments might be the first to note

changes in the epidemiology of an

infectious disease, to initiate a public

health department referral to identify the

causative organism, and to treat patients

affected by the exposure. After a

chemical or radiological attack, patients

might require decontamination at the

hospital if they have bypassed the

firefighters or emergency medical

technicians at the exposure site. After an

explosion, large numbers of injured

patients might be brought to emergency

departments for treatment. In any of

these scenarios, hospitals would

experience an influx of patients who

may have been exposed and have

medical or psychological issues to be

addressed.

Because of the heavy demand

placed on their services at the time of

an attack, hospitals need to be prepared

to handle the workload. Because the

most common terrorist attacks to date

have been explosive or incendiary (car

bombs, airplanes full of fuel, etc.),

hospitals must be prepared to treat an

influx of trauma cases. Hospitals must

also be prepared to diagnose and treat

diseases caused by CDC Class A

bioterrorism agents (smallpox, anthrax,

plague, botulism, tularemia, and

hemorrhagic fever). Although hospitals

are required to have disaster response

plans to be accredited by the Joint

Commission on Accreditation of

Healthcare Organizations (JCAHO), the

standard elements of these plans are still

quite general regarding terrorism (4).

The 2003 NHAMCS Bioterrorism

and Mass Casualty Preparedness

Supplement surveyed hospitals on their

preparedness for such attacks by asking

about the content of emergency response

plans, training for terrorism response,

experiences with internal and external

disaster drills, and availability of

specialized equipment such as

decontamination showers, personal

protective suits, and negative pressure

isolation rooms.

This report provides a descriptive

summary of the responses to the

supplement from which national

estimates of preparedness can be

generated for the overall universe of

U.S. hospitals. Other current research

efforts involving the survey go beyond

the descriptive work reported here and

delve into hospital characteristics

associated with greater preparedness in

the areas of emergency response

planning, training and practicing for

terrorism, and equipment and specialized

care units for terrorism-related incidents.

Methods

The NHAMCS is an annual

probability sample survey of nonFederal general and short-stay hospitals

(those with an average length of stay of

less than 30 days) within the 50 States

and the District of Columbia. Children’s

hospitals were included in the sampling

frame. Federal hospitals, hospital units

of institutions, and hospitals with less

than six beds were ineligible for the

NHAMCS. Hospitals with a 24-hour

emergency department (ED) or

outpatient department (OPD) supervised

by a physician were included. Hospitals

without an ED or whose OPD was

comprised solely of ancillary clinics

(e.g., radiology, laboratory services,

physical rehabilitation, renal dialysis)

were ineligible to participate. The

sampling frame consisted of hospitals

listed in the 1991 Verispan Hospital

Database (VHD), which was updated

using the 2000 VHD to allow the

inclusion of hospitals that opened or

changed their eligibility status since the

previous sample in 1991. The VHD was

formerly known as the SMG Hospital

Database. An additional sample of 66

hospitals (identified as proprietary or as

located in nonmetropolitan statistical

areas) was selected from the 2002 VHD.

Hospitals were randomly assigned to 1

of 13 4-week reporting periods scattered

over the entire year. The data were

weighted according to the inverse

probability of hospital selection and a

nonresponse adjustment factor. Thus,

estimates are considered representative

of similar health care facilities over the

entire Nation.

Terrorism preparedness items were

added to the 2003 NHAMCS in a

special supplement (see ‘‘Technical

Notes’’). This was administered to the

same hospitals as those sampled for the

NHAMCS. The supplement used the

first 2 stages of the regular NHAMCS

design involving 112 geographic

primary sampling units (PSU) and

hospitals that have emergency or

outpatient departments within PSUs. For

this analysis, the supplement included

questions about updates of the hospital’s

emergency response plan since

September 11, 2001; whether that plan

addressed natural disasters and

biological, chemical, nuclearradiological, and explosive-incendiary

terrorism incidents; collaboration with

outside organizations for planning; key

elements of the plans such as

establishment of alternate care sites;

clinician training in the management of

exposures to weaponizable infectious

diseases, chemicals, and nuclear

materials; drills on aspects of the

response plans; and equipment and bed

capacity available at the hospital. The

content of the questionnaire was based

on the JCAHO list of elements that are

important to have in an emergency

response plan, training questions about

the CDC Class A bioterrorism agents,

and drill scenarios suggested by

bioterrorism researchers at HRSA, Johns

Hopkins University, George Washington

University, the American Hospital

Association, the Office of Emergency

Preparedness at the Department of

Health and Human Services, the

Government Accountability Office, the

Office of Management and Budget, and

the Centers for Medicare and Medicaid

Services. The collection form was pilot

tested in October 2002 and refined and
Advance Data No. 364 + September 27, 2005 3

implemented in December 2002. During

the 2003 NHAMCS induction interview

with the administrator of each sampled

hospital, the supplement was left for the

bioterrorism coordinator to complete and

return to the interviewer. Of 546

hospitals sampled in 2003, 462 were in

scope for the NHAMCS. Data were

received from 399 hospitals, for a

response rate of 86.4 percent. This

represented a weighted national total of

approximately 5,000 hospitals. The

percentage of missing values (re-coded

into ‘‘no’’ or ‘‘blank’’ responses for any

one variable) was less than 3%, except

where noted in the tables. Descriptive

statistics with their corresponding

measures of sampling error were

generated using SUDAAN-9.0 software

(RTI International), which takes into

account the complex sample design of

the NHAMCS (5). Analyses involving

comparisons across subgroups used a

chi-square test statistic evaluated at a

0.05 level of significance.

Results

Emergency Response Plans

Nearly all hospitals had emergency

terrorism response plans. The majority

had revised their plans since September

11, 2001 (92.3 percent), but 6.3 percent

had not. Few hospitals had no response

plan (1.5 percent). Table 1 shows the

percent distribution of all hospitals (with

or without plans) and the percentage of

hospitals with revised plans by selected

hospital characteristics. Only teaching

hospital status was associated with a

greater likelihood of having a revised

plan (p< 0.05). Among hospitals with a

response plan, 97.3 percent addressed

(77.7 percent), emergency medical

services (71.9 percent), and fire

departments (65.7 percent) (table 3).

About three-quarters of hospitals

(76.4 percent) defined their role in

community-wide planning in their

response plans, and 75.9 percent

provided for cooperative planning with

other area health care facilities.

However, only 46.1 percent of hospitals

had memoranda of understanding with

outlying hospitals to accept inpatients

during a declared disaster (table 4).

In the area of internal disaster

planning, 73.1 percent of hospitals

planned to cancel elective procedures

and admissions during an emergency,

66.8 percent had plans for establishing

an alternate care site, and 60.8 percent

had plans for medical utilization of

nonclinical hospital space. However,

only 36.6 percent of hospitals planned to

convert their postanesthesia care unit

(where postoperative patients are

monitored as they awake from

anesthesia) to augment intensive care

capacity. Only 27.3 percent planned to

activate decommissioned ward space

(i.e., opening closed hospital bed

capacity) during an emergency. The

majority of hospitals (60.1 percent)

provided for coordinated supply-chain

management of critical supplies and

pharmaceuticals in their response plans,

which includes such methods as

vendor-managed pharmaceutical

inventories to ensure that supplies are

replaced before becoming outdated. Less

than half (44.1 percent) of hospitals had

plans to stockpile antibiotics and other

supplies (table 4).

Most hospitals (87.4 percent) were

members of a regional interagency

disaster preparedness task force. Only

about one-third of hospitals

(34.3 percent) were designated to

receive patients through the National

Disaster Medical System (NDMS).

Another one-third of hospitals were

unaware of their NDMS designation

status (table 5).

Training in Emergency

Response

Three-quarters (75.0 percent) of

hospitals had key hospital personnel

trained to implement a formal incident

command system, which is an organized

procedure for managing resources and

personnel during an emergency (table 5).

Staff members at most hospitals

(88.5 percent) had received training

since September 11, 2001, in the

identification, diagnosis, and treatment

of any of the biological agents studied

in this survey (smallpox, anthrax,

plague, botulism, tularemia, viral

hemorrhagic fever, viral encephalitis)

(figure 1). Training on individual

diseases or conditions received by

hospital staff physicians, interns,

residents, physician assistants, registered

nurses, licensed practical nurses,

laboratory staff, and others was most

frequent for smallpox (86.7 percent),

anthrax (83.7 percent), and chemical

exposures (80.2 percent) (table 6 and

figures 1 and 2). Data on training by

professional category are shown in

table 7 and figure 3. The most frequent

sources of preparedness training were

hospitals (61.4 percent) and State or

natural disasters, 85.5 percent addressed

chemical terrorism, 84.8 percent

addressed biological terrorism,

77.2 percent addressed nuclear or

radiological terrorism, 76.9 percent

addressed explosive or incendiary

incidents, and 63.5 percent addressed all

five of these incident types (table 2).

Almost all hospitals (95.4 percent)

had provisions in their plans to contact

outside entities. The most frequent

outside entities were State or local

public health departments (81.9 percent),

State or local law enforcement

Figure 1. Percentage of hospitals that trained their staff in emergency response, by

selected subject areas: United States, 2003
4 Advance Data No. 364 + September 27, 2005

Figure 2. Percentage of hospitals that trained their staff in bioterrorism response, by

biological agent: United States, 2003

local public health departments

(44.8 percent) (table 8).

Mass Casualty Drills

Nine out of 10 hospitals

(88.4 percent) participated in an internal

mass casualty drill since September 11,

2001, and 87.1 percent conducted a

mass casualty drill in collaboration with

other organizations. For the internal

drills, the most common scenario was a

general disaster and emergency response

(69.7 percent). Other scenarios included

chemical release (44.9 percent),

biological attack (37.5 percent),

explosive or incendiary attack

(21.3 percent), and nuclear or

radiological attack (15.4 percent). In

contrast to biological attacks, drills

involving severe epidemics were staged

by only 7.1 percent of hospitals

(table 9). Scenarios for collaborative

drills followed a similar pattern. The

Figure 3. Percentage of hospitals that trained their staff in terrorism response, by

professional category: United States, 2003

organizations with which hospitals

collaborated most often for mass

casualty drills were emergency medical

services (70.9 percent), fire departments

(67.1 percent), and State or local law

enforcement (64.5 percent) (table 10).

Mass Casualty Resources

Hospitals were asked to quantify

certain available resources that would be

useful in a mass casualty incident.

Among hospitals with mechanical

ventilators, there was an average of 7.8

per 100 beds (table 11). Among

hospitals with personal protective

hazardous materials suits, there was an

average of 9.4 per 100 beds. On

average, there were 4.3 negative

pressure isolation rooms and 13.8

critical care beds per 100 beds,

including those in adult and pediatric

intensive care, coronary care, and

postanesthesia care units. Among

hospitals with decontamination showers,

there was an average of 1.5 per 100

beds, but the capacity of these showers

was not ascertained in this survey.

Discussion

Almost all hospitals have natural

disaster plans because it is a JCAHO

accreditation requirement (4) to hold

annual disaster drills on scenarios such

as floods, hurricanes, earthquakes,

tornados, or others that have stressed

health care systems on a regular basis.

Although it is natural to focus on

natural disasters during preparedness

planning, some gaps in preparedness for

man-made disasters would be expected

because terrorism is not within the usual

experience of U.S. hospitals. In a

convenience sample of 30 hospitals

from West Virginia, Pennsylvania,

Maryland, Virginia, and the District of

Columbia, Treat et al. (6) found that

only 27 percent had addressed weapons

of mass destruction in their disaster

plans. In this pre-September 11 survey,

none of the rural hospital respondents

believed that their hospitals were

prepared for biological, chemical, or

nuclear disasters. Most of the urban

hospital respondents believed their

hospitals were only somewhat prepared.

In a 1998 survey of 186 emergency
Advance Data No. 364 + September 27, 2005 5

departments in Alaska, Idaho, Oregon,

and Washington, Wetter et al. (3) found

that 80 percent of the hospitals had

hazardous materials response plans.

However, only 17 percent had chemical

weapons plans, and only 12 percent had

plans for biological weapons response.

The NHAMCS supplement was

conducted throughout 2003 and reflects

a heightened level of urgency due to the

airline terrorist attacks of September 11,

2001, and the anthrax outbreak of 2001.

Planning for biological scenarios was

quite common despite the rarity of these

events in actual experience. The

Government Accountability Office

(GAO) surveyed 1,482 urban hospitals

between May and September 2002 as to

their preparedness for biological

terrorism. Approximately 81 percent of

these hospitals had a written emergency

response plan that addressed

bioterrorism (7). The NHAMCS results

for 2003 show a further increase to

94 percent for urban hospitals having

revised emergency response plans for

terrorism in general (table 1). Because

funding from the Bioterrorism Hospital

Preparedness Program of the Health

Resources and Services Administration

was focused exclusively on biological

preparedness until FY 2003, this may

have also played a role in the emphasis

on this contingency (8). However,

because funds from that program had

not been fully distributed to hospitals by

the time the 2003 NHAMCS was

fielded, it will be interesting to follow

up on this issue in the 2004 iteration of

this survey (1,2).

Planning for chemical attacks is

similar to that for biological attacks and

ahead of nuclear-radiological exposures.

Many communities have hazardous

materials teams because of the high

potential for industrial or farming

exposures. Also, there has been

experience in recent history with

chemical attacks, such as the sarin

incident in Tokyo (9). Wetter et al. (3)

found that hospitals within 35 miles of a

military chemical weapons depot were

five times as likely as other hospitals to

have a chemical weapons response plan,

but no more likely to have a plan for

biological weapons.

Plans for explosive or incendiary

incidents were reported the least

frequently of all the scenarios in this

survey. However, one would expect

planning for explosions to rank much

higher than for other forms of terrorism

because this is the most frequent means

employed by terrorists, both

domestically (e.g., World Trade Center)

and internationally (e.g., Iraq, Madrid,

and London). But the $125 million of

funding from the HRSA Bioterrorism

Hospital Preparedness Program did not

cover explosions or fires in FY 2002,

and separate HRSA funding for

Statewide trauma systems nationwide

has been level at approximately $2

million per year from FY 2001 to FY

2004 (10).

The majority of hospitals had

provisions in their response plans for

cooperation with appropriate outside

entities. However, less than half reported

having actual written memoranda of

understanding with other facilities on at

least one dimension of mutual

aid—being able to transfer patients

elsewhere when their surge capacity is

exceeded. This replicated the preSeptember 11 findings of Treat et al.

(6), who found that although 97 percent

of their hospitals had patient overflow

plans involving other facilities, none of

them had specific agreements in place

for mass disaster casualties. The

post-September 11 GAO study was

more optimistic for urban hospitals in

that 69 percent of their sample had

agreements to share resources during a

biological incident (7). One area for

future research might be to frame the

questions in terms of actual

arrangements in place instead of plans

to do so.

One interesting anomaly in the

results was the high percentage of

hospitals that were unaware of whether

they were designated by NDMS to

receive patients in a disaster. It is

possible that the NDMS designation had

been granted at some time in the distant

past, but never actually tested because

of the low prevalence of mass casualty

disasters. Given that, it may not be

surprising that the institutional memory

of such a designation might have been

lost, especially if the hospital had

undergone changes in ownership or

administration since it was granted. This

finding suggests that hospital drills

might be crafted to reflect the NDMS

designation status, thus encouraging the

hospital to review its status.

It is encouraging that such a high

percentage of registered and licensed

practical nurses had received training in

at least one area of terrorism

preparedness, and that staff physicians

were not far behind. However, it is

puzzling that interns and residents lag so

far behind their senior colleagues

because one might expect that

physicians in training would be at the

forefront of acquiring new knowledge.

The high percentage of nurses who

received training is reassuring because

the pre-2001 survey done by Treat et al.

(6) found that staff at less than onequarter of hospitals in the States

surrounding Washington, DC, had

received education on weapons of mass

destruction. Wetter et al. (3) found that

only 23 percent of hospitals in the

Northwest had offered training before

September 11 on chemical weapons

response, and only 19 percent had

offered biological weapons response

training.

In their 2002 survey, the GAO

found that 70 percent of urban hospitals

had trained their staff for all six of the

CDC Class A biological agents

(smallpox, anthrax, plague, botulism,

tularemia, and hemorrhagic fever) (7).

However, in a separate analysis of urban

hospitals responding to the 2003

NHAMCS supplement, none of the

sample had trained their staff in all six

agents. It is possible that differing

methodologies might be partially

responsible for this discrepancy. The

GAO used a mailed survey with

followup reminders by mail and

telephone, and the NHAMCS survey

was presented to the bioterrorism

coordinators by on-site field

representatives during personal

interviews. However, although the GAO

report was more optimistic than the

NHAMCS for five of the six agents

individually (smallpox being equal), the

discrepancies were not as marked. For

example, at the high end of the scale,

GAO found that 93 percent of urban

hospitals had offered training for

anthrax, and 86 percent of the

NHAMCS urban sample had. At the low

end, GAO found that 71 percent of
6 Advance Data No. 364 + September 27, 2005

urban hospitals had offered training for

viral hemorrhagic fever, and only

53 percent of the NHAMCS urban

sample had.

The top training priorities that are

demonstrated in this study are

interesting because they are a mix of

more likely occurrences (such as

chemical incidents) and less likely, but

high profile occurrences (such as

smallpox and anthrax). Training for the

rest of the infectious diseases is perhaps

more reflective of their rarity. Again,

this demonstrates a post-September 11

shift in thinking. The Treat et al. (6)

survey found that only 10 percent of

hospitals drilled on chemical or nuclear

attacks, and only 3 percent drilled on

biological weapons.

It is interesting to note the

discrepancy between hospital drills for

biological attacks and those for severe

epidemics. The percentage of hospitals

drilling on biological scenarios more

closely approximates that for chemical

attacks. Future research might define

more precisely what skills are being

drilled in a biological attack response,

especially whether biological response is

being thought of in terms of acute

decontamination of a known aerosol

exposure rather than in terms of an

infectious disease epidemic beginning

some days after an apparent exposure.

In the aftermath of the devastation

wrought by Hurricane Katrina, this

report provides information that may

assist in the formulation of future

policies and procedures on preparedness

for such natural disasters. Hospitals

reported that their drills lagged behind

their written response plans, formal

patient transfer arrangements lagged

behind cooperative planning with other

hospitals, and drills that included public

health departments and volunteer

organizations lagged behind drills that

included emergency medical services

and fire departments. Knowledge of

these shortfalls may offer opportunities

for future improvement efforts. As

hospitals review their plans in light of

the problems experienced during this

disaster, the lessons learned may also

affect future data collection on the

ability of hospitals to respond to all

types of emergencies.

References

1. Hearne SA, Davis M, Segal LM, et

al. Ready or not? Protecting the

public’s health in the age of

bioterrorism. Trust for America’s

Health. December 2003.

www.healthyamericans.org.

2. McHugh M, Staiti AB, Felland LE.

How prepared are Americans for

public health emergencies? Twelve

communities weigh in. Health Aff;

23:201–9; May-June 2004.

3. Wetter DC, Daniell WE, Treser CD.

Hospital preparedness for victims of

chemical or biological terrorism. Am

J Public Health. 91:710–6; May

2001.

4. Joint Commission on Accreditation

of Healthcare Organizations.

Emergency management standards —

EC.2.9.1. Joint Commission

Resources, Oakbrook Terrace,

Illinois. January 1, 2003.

5. Research Triangle Institute SUDAAN

(Release 9.0.1) [Computer Software].

Research Triangle Park, NC:

Research Triangle Institute. 2005.

6. Treat KN, Williams JM, Furbee PM,

et al. Hospital preparedness for

weapons of mass destruction

incidents: an initial assessment. Ann

Emerg Med. 38:562–5; November

2001.

7. General Accounting Office. Hospital

preparedness — most urban hospitals

have emergency plans but lack

certain capacities for bioterrorism

response. GAO-03–924. Washington.

U.S. General Accounting Office.

2003.

8. Health Resources and Services

Administration. National bioterrorism

hospital preparedness program

cooperative agreement guidance.

2003.

9. Arizona Department of Health

Services. History of biowarfare and

bioterrorism. August 3, 2004.

www.azdhs.gov/phs/edc/edrp/es/

bthistor2.htm.

10. Health Resources and Services

Administration. FY 2004 State

trauma project abstracts and funding

profiles. www.hrsa.gov/trauma/states/.
Advance Data No. 364 + September 27, 2005 7

Table 1. Percent distribution of all hospitals and percentage of hospitals having revised emergency response plans since September 11,

2001 (with standard errors), by hospital characteristics: United States, 2003

Percent with plan

Percent revised since Standard

Hospital characteristic distribution Standard error September 11, 2001 error

All hospitals ............................... 100.0 . . . 92.3 2.3

Geographic region

Northeast ................................ 16.3 1.6 92.3 3.5

Midwest ................................. 28.3 2.8 91.3 4.5

South ................................... 37.7 2.9 90.5 4.6

West ................................... 17.8 2.7 97.5 1.7

Metropolitan status

Metropolitan statistical area ..................... 60.0 3.6 94.2 2.5

Nonmetropolitan statistical area ................... 40.0 3.6 89.4 4.3

Ownership

Voluntary, nonprofit .......................... 62.0 4.3 94.1 2.1

Government ............................... 26.3 4.2 84.5 6.2

Proprietary................................ 11.7 2.1 99.8 0.2

Teaching hospital

Yes .................................... 6.3 0.8 100.0 0.0

No ..................................... 93.7 0.8 91.7 2.4

Number of hospital beds

Less than 100.............................. 59.0 2.7 88.6 3.7

100–199 ................................. 20.4 2.4 97.7 2.0

200–299 ................................. 10.0 1.6 97.6 1.8

300 or more ............................... 10.7 1.2 97.0 2.2

Has a 24-hour emergency department

Yes .................................... 92.7 2.9 91.7 2.4

No ..................................... *7.3 2.9 99.2 0.9

...Category not applicable.

0.0 Quantity more than zero but less than 0.05.

* Figure does not meet standards of reliability or precision.

NOTE: Numbers may not add to totals because of rounding.

Table 2. Percentage (with standard errors) of hospitals with emergency response plans for selected types of incidents: United States,

2003

Type of incident

Percent

of hospitals

Standard

error

Natural disaster ...........................................

Chemical ...............................................

Biological ...............................................

Nuclear or radiologic exposure ..................................

Explosive or incendiary exposure ................................

All types of incidents ........................................

97.3

85.5

84.8

77.2

76.9

63.5

1.0

2.4

2.6

3.5

4.0

4.3
8 Advance Data No. 364 + September 27, 2005

Table 3. Percentage (with standard errors) of hospitals having provisions in their emergency bioterror response plans for contacting

outside entities, by type of outside entity to be contacted: United States, 2003

Percent Standard

Type of outside entity contact of hospitals error

Any entity ....................................... 95.4 1.6

State or local health departments ......................... 81.9 3.4

State or local police ................................. 77.7 2.9

Emergency medical services ............................ 71.9 3.9

Fire department .................................... 65.7 4.1

Other State or local government.......................... 59.9 3.5

Hazardous materials teams............................. 58.3 3.9

Centers for Disease Control and Prevention .................. 52.4 4.1

Other hospitals .................................... 50.7 4.0

Federal Bureau of Investigation .......................... 42.5 4.1

Utilities ......................................... 32.0 3.6

Vendors......................................... 28.9 4.1

Local political official ................................. 19.7 2.4

Other Federal agency ................................ 11.7 1.7

Other laboratories .................................. 8.4 2.2

Table 4. Percentage (with standard errors) of hospitals having specific components in their emergency response plans, by type of plan

component: United States, 2003

Percent Standard

Type of plan component of hospitals error

Definition of role in community planning ..................... 76.4 3.5

Cooperative planning with other health care facilities ............. 75.9 3.8

Cancellation of elective procedures and admissions ............. 73.1 4.2

Establishment of an alternate care site...................... 66.8 3.0

Medical utilization of nonclinical space ...................... 60.8 3.7

Coordinated supply-chain management ..................... 60.1 3.8

Memoranda of understanding with hospitals to accept inpatients...... 46.1 4.1

Stockpiling antibiotics and supplies ........................ 44.1 3.5

Conversion of post-anesthesia unit to intensive care unit .......... 36.6 3.6

Activation of decommissioned wards ....................... 27.3 2.7

Table 5. Percent distribution (with standard errors) of hospitals involved in interagency task forces, designated by the National Disaster

Medical System, and trained in incident command: United States, 2003

Percent Standard

Hospital characteristic distribution error

All hospitals ...................................... 100.0 . . .

Interagency task force

Member......................................... 87.4 4.0

Not a member..................................... *8.0 3.7

Unknown ........................................ *4.6 1.9

National Disaster Medical System

Designated to receive patients........................... 34.3 2.9

Not designated .................................... 32.2 4.1

Unknown ........................................ 33.5 3.3

Key personnel in incident command system

Trained ......................................... 75.0 3.8

Not trained ....................................... 20.8 3.7

Unknown ........................................ *4.2 1.6

...Category not applicable.

* Figure does not meet standards of reliability or precision.

NOTE: Numbers may not add to totals because of rounding.
Advance Data No. 364 + September 27, 2005 9

Table 6. Percentage (with standard error) of hospitals whose staff have received training, by disease or exposure: United States, 2003

Percent Standard

Disease or exposure of hospitals error

Smallpox ............................................... 86.7 2.4

Anthrax ................................................ 83.7 3.1

Chemical exposure ......................................... 80.2 2.7

Nuclear or radiologic exposure .................................. 66.4 3.3

Botulism................................................ 65.0 3.7

Plague................................................. 61.0 4.0

Viral encephalitis .......................................... 53.2 3.7

Tularemia ............................................... 51.3 3.9

Viral hemorrhagic fever ...................................... 51.2 3.4

NOTE: Staff members include staff physicians, interns or residents, physician assistants or nurse practitioners, nurses, laboratory staff, and others.

Table 7. Percentage (with standard errors) of hospitals that trained their staff in any terrorism-related disease or condition, by type of

profession: United States, 2003

Type of clinician

Percent

of hospitals

Standard

error

Nurses ................................................

Staff physicians ...........................................

Laboratory staff ...........................................

Physician assistants or nurse practitioners ..........................

Residents or interns ........................................

92.1

82.5

72.9

53.1

49.2

2.2

3.0

3.8

5.2

5.6

NOTE: Terrorism-related diseases or conditions include smallpox, anthrax, plague, botulism, tularemia, viral hemorrhagic fever, viral encephalitis, and chemical, nuclear, and radiologic exposures.

Table 8. Percentage (with standard errors) of hospitals that used selected terrorism-preparedness training sources, by training source:

United States, 2003

Percent Standard

Training source of hospitals error

Hospital ................................................ 61.4 3.3

State or local public health department............................. 44.8 3.7

Professional association ...................................... 33.9 3.8

Other State or local government agency ............................ 24.5 3.5

Federal agency ........................................... 10.1 2.2

Private vendor ............................................ 8.4 1.7

Insurance organization....................................... *0.1 0.1

Other ................................................. 19.3 3.8

* Figure does not meet standards of reliability or precision.

Table 9. Percentage (with standard errors) of hospitals participating in internal and external mass casualty drills, by type of drill

scenario: United States, 2003

Internal drills External drills

Scenario

Percent

of hospitals

Standard

error

Percent

of hospitals Standarderror

Hospitals staging drills....................

General disaster or emergency response ........

Chemical release .......................

Biologic attack.........................

Explosive or incendiary attack ...............

Nuclear or radiologic attack.................

Severe epidemic .......................

88.4

69.7

44.9

37.5

21.3

15.4

7.1

2.7

3.7

3.9

3.5

3.2

2.1

1.4

87.1

66.4

44.1

33.9

24.2

15.2

4.8

2.8

4.0

3.5

3.2

3.4

2.2

0.9
10 Advance Data No. 364 + September 27, 2005

Table 10. Percentage (with standard errors) of hospitals collaborating in external mass casualty drills, by type of collaborating

organization: United States, 2003

Percent Standard

Type of collaborating organization of hospitals error

Emergency medical services ................................... 70.9 4.0

Fire department ........................................... 67.1 3.9

State or local law enforcement .................................. 64.5 3.7

Other State or local government agencies ........................... 52.0 4.0

Other hospitals or hospital associations ............................ 45.9 3.6

State or local public health department............................. 45.6 4.0

Hazardous materials teams .................................... 43.8 3.5

American Red Cross ........................................ 21.3 2.4

Other volunteer organizations .................................. 15.6 1.7

Key vendors of medical supplies................................. *7.0 3.0

Other ................................................. 17.5 3.9

* Figure does not meet standards of reliability or precision.

Table 11. Mean number and rate (with standard errors) of selected specialized equipment per responding hospital: United States, 2003

Standard Mean per 100 Standard

Type of equipment Mean error hospital beds error

Intensive care beds ........................ 20.3 1.4 13.8 0.9

Personal protective suits ..................... 12.7 1.5 9.4 1.3

Ventilators.............................. 11.0 0.8 7.8 0.9

Isolation rooms........................... 6.0 0.4 4.3 0.3

Decontamination showers .................... 1.5 0.1 1.5 0.2
Advance Data No. 364

+ September 27, 2005 11

Technical Notes
12 Advance Data No. 364 + September 27, 2005
Advance Data No. 364 + September 27, 2005 13
14 Advance Data No. 364 + September 27, 2005
16 Advance Data No. 364 + September 27, 2005

Suggested citation

Niska RW, Burt CW. Bioterrorism and mass

casualty preparedness in hospitals: United

States, 2003. Advance data from vital and

health statistics; no 364. Hyattsville, MD:

National Center for Health Statistics. 2005.

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