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

Surge Capacity—Education and

Training for a Qualified Workforce

No. 7

Introduction

Surge capacity is a health care

system’s ability to expand

quickly beyond normal services

to meet an increased demand

for medical care in the event of

bioterrorism or other largescale public health emergencies.

A health system’s ability to expand its

services rapidly depends on the

availability of qualified personnel and

their ability to perform tasks assigned to

them. Building a qualified workforce

requires that disaster planners recruit

previously untapped resources, such as

non-active nurses, and provide training to

ensure that these personnel are prepared

to respond to significantly increased surge

capacity requirements.

On March 2, 2004, the Agency for

Healthcare Research and Quality (AHRQ)

sponsored a Web-assisted audio

conference that examined how education

and training efforts are being used to

create and maintain the readiness of an

appropriately trained workforce that can

respond to a sudden increase in surge

capacity needs. Presentations were made

by the following researchers and

practitioners:

▲ Joan P. Cioffi, Ph.D., Centers for

Disease Control and Prevention, U.S.

Department of Health and Human

Services, Atlanta;

▲ Terri Spear, Ed.M., Health Resources

and Services Administration, U.S.

Department of Health and Human

Services, Rockville, Md.;

▲ Michael Allswede, D.O., University of

Pittsburgh Medical Center Health

System, Pittsburgh; and

▲ Betsy Weiner, Ph.D., R.N., B.C.,

FAAN, Vanderbilt University,

Nashville, Tenn.

This issue brief summarizes those

presentations and the question and answer

period that followed. Dr. Cioffi and Ms.

Spear described education and training

initiatives sponsored by the Centers for

Advancing Excellence in Health Care • www.ahrq.gov

Agency for Healthcare Research and Quality
Disease Control and Prevention (CDC)

and the Health Resources and Services

Administration (HRSA), respectively.

Dr. Allswede described his AHRQfunded project to develop noncontiguous training that teaches

hospital personnel the skills they need

to respond to bioterrorism or other

large-scale public health emergencies.

Dr. Weiner discussed her project, also

funded by AHRQ, to develop and

evaluate Web-based and face-to-face

training modules to prepare volunteer

nurses to respond to public health

emergencies. A recurring theme of the

audio conference was the importance of

competency-based training. 

CDC Funding for

Education and Training

One of CDC’s top strategic

imperatives is to build a competent

and sustainable public health

workforce that can respond to a

bioterrorist event or other public health

emergency. “CDC has developed a

national public health strategy for

terrorism preparedness and response

that will guide our agency’s efforts

over the next five years,” said the

CDC’s Joan Cioffi. Dr. Cioffi

described education and training

activities in three broad categories.

The first category is State and local

education and training, which is

mandated by CDC’s Cooperative

Agreement on Public Health

Preparedness and Response for

Bioterrorism. The Cooperative

Agreement provides grants to 50

States, the District of Columbia, eight

territories, and three cities. Grantees

are expected to conduct needs

assessments, develop training plans,

and have some capacity to maintain

data on who has been trained. CDC

plans to disseminate best practices on

a regional and national basis and is

currently developing system

performance indicators and exercises

and drills to help grantees refine their

training activities. 

The second category is partnerships.

The Centers for Public Health

Preparedness program includes 23

schools of public health and 13

specialty centers, including schools of

medicine, nursing, veterinary

medicine, and law. The Centers work

with state and local partners to meet

identified community needs. For

example, the University of Illinois at

Chicago is working with the Illinois

Department of Health and the City of

Chicago to provide needs assessments

for training of all public health staff

and to develop customized training.

CDC has also formed partnerships

through outreach to clinicians. In

response to clinicians’ desire for

guidance from their professional peers

and the organizations they typically

work with, CDC has established

relationships with the Association of

American Medical Colleges and eight

specialty societies. They are working

collaboratively to develop customized

information for more than 300,000

clinicians and health care professionals

who have links to these organizations.

The third broad category is as a direct

provider of education and training,

both internally and externally.

Internally, CDC must train its

emergency operations staff and field

staff for terrorism preparedness.

External training is provided through

nine different CDC offices, centers,

and agencies. The Office of Terrorism

Preparedness and Emergency

Response coordinates the various

education and training programs to

identify gaps and avoid duplications. 

Dr. Cioffi summarized CDC’s role in

providing critical health information as

being part of a continuum from

communication to professional

education. CDC has learned from its

experience with the anthrax attacks,

the spread of SARS, and other

emerging health threats that two

strategies are needed. CDC’s “just in

case”strategy involves making

educational information available to

frontline public health professionals

and clinicians, helping to prepare them

to recognize illnesses that might be

caused by a terrorist agent. A good

example of that strategy is the wealth

of information on smallpox that is

available on CDC’s Web site. 

The second strategy, “just in time,”

involves being able to provide

information that can be immediately

accessed by public health professionals

and clinicians when they are presented

with a case that may have been

affected by a bioterrorist event.

Clinical guidance and medical

management protocols can be made

available through hotlines, health alerts

and advisories, emergency satellite

videoconferences, and other means.

The starting point for both strategies is

CDC’s Web site (www.cdc.gov). 

HRSA’s National

Bioterrorism Hospital

Preparedness Program

The purpose of HRSA’s National

Bioterrorism Hospital Preparedness

Program is to “ready hospitals and

supporting health care systems to

deliver coordinated and effective care

to victims of terrorism and other

public health emergencies.” Guidance

in the first year of the program, FY

2002, made education and training a

2
3

secondary priority, and program

guidance for FY 2003 made it

optional. Nevertheless, HRSA’s

detailed review of applications for

continuation funding found that 100

percent of its grantee hospitals are

addressing education and training for

bioterrorism and other public health

emergencies. 

HRSA’s analysis of the education and

training being provided by grantee

hospitals included who was being

trained, what topics were being

addressed, and what educational

methodologies were being used.

Because it is a hospital-based

program, the training of laboratory

personnel and medicine, mental

health, nursing, and allied health

professionals was expected. Hospital

training has also targeted fire, police,

and emergency medical personnel. 

The topic most frequently addressed

during training is worker safety, which

focuses on how to use personal

protective equipment and how to

perform basic activities while wearing

it. The second most frequently

addressed topic is psychosocial issues

for both patients and providers. Other

topics include responding to

biological, chemical, and radiological

events; incident command; risk

communication; and treating special

populations.

Grantees reported using several

different educational methodologies.

Sixty-nine percent reported using face

to face training, either “one on one” or

“one to many.” Sixty-one percent are

using distance learning approaches

such as Web-based training and video

and other tape, 55 percent are using

field exercises or drills, and 52 percent

have distributed written learning

materials. 

While it is clear that hospitals are

engaged in education and training for

bioterrorism preparedness, neither the

hospitals nor HRSA can answer one

overriding question today. That

question is, “What percentage of the

Nation’s health care workforce is

prepared to respond competently to a

public health emergency?” To help

answer that question, HRSA is

assisting awardees in shifting from

content-focused training toward

competency-based training. Instead of

acquiring content knowledge about

smallpox, anthrax, or radiation illness,

for example, hospital employees

would be expected to be able to

describe and demonstrate their

emergency response role. 

“Competency-based education

increases the relationship between

training and workplace applicability,”

said HRSA’s Terri Spear. “Health care

providers will have a measure to

assess for themselves that they are as

prepared as they can be in response to

an event and to be able to provide the

best care possible for the population

that they are serving.” By offering a

clearer definition of provider

preparedness, competency-based

training also improves the

transferability and comparability of

training across health care facilities.

Further information about HRSA’s

National Hospital Bioterrorism

Program is available at

www.hrsa.gov/bioterrorism.htm. 

Non-Contiguous

Training

Dr. Michael Allswede is the principal

investigator on an AHRQ-sponsored

project to develop a competency-based

training approach called “noncontiguous training” as a method of

teaching hospital personnel the skills

needed to respond to bioterrorism or

other large-scale public health

emergencies. Biological or chemical

or radiation events are different from

other emergencies because they place

the medical caregiver at risk. They may

place patients already in the hospital at

risk and may place the facility itself at

risk. Keeping caregivers, patients, and

the facility safe requires new skill

development and adaptation of other

technical skills.

Those new skills are better taught on

an individual level rather than in a

general drill. Non-contiguous training

divides the hospital disaster plan into

key capacities and key skills that are

then assigned to individual staff

members. The skill level of each staff

member is assessed and needed skills

are tracked as they are acquired to

give each person an individualized

training program. Training is divided

into segments so that the staff member

can learn the skills during downtime

or on regular CME training days. In

effect, each person has his or her own

individual disaster plan. When a

general drill is then held, or if an

emergency event occurs, each

individual knows what he or she is

supposed to do. 

The concept of non-contiguous

training has been borrowed from the

U.S. Navy’s Afloat Training Exercise

and Management System (ATEAMS).

A Navy ship is similar to a hospital in

disaster emergency training, said

Allswede, in that “you cannot just stop

a ship and have it go through a

training day and then start it going

again.” Similarly, hospitals cannot stop

their normal functions to take part in a

drill. Moreover, drills are often

scheduled at the convenience of

individuals from other sectors of the
4

community, such as the police. (For

example, drills may be scheduled in the

morning, which is optimal for the

police force but almost always very

busy for hospitals.) In addition, drills

are costly and consume significant staff

time. At the University of Pittsburgh

Medical Center, for example, a disaster

drill in the emergency department costs

$3,000 per hour in staff salary alone.

Non-contiguous training is intended to

disseminate knowledge and skills prior

to a disaster drill, thereby making the

drill more effective and efficient.

The program being developed by Dr.

Allswede and his colleagues has also

borrowed a concept from the U.S. Army

called the “FAPV” sequence, which

stands for Familiarize, Acquire,

Practice, and Validate. The first two

components lend themselves to noncontiguous training. The Familiarize

component includes classic classroom

teaching, distance learning, video

interface, and memory enhancement

tools like mnemonics. The Acquire

component employs two

methodologies. One is virtual interface

using an interactive computer program.

The second is a training room

containing approximately 40

physiologic mannequins that have

pulses, can talk, and can exhibit a wide

range of symptoms. Medical staff can

practice treating symptoms in a

controlled environment. 

The Practice component is best done in

a standard drill format. The focus of the

drill is not on whether the individual

knows what to do, but whether

individuals and groups together can

apply the skills they have acquired to

accomplish their objective. The Validate

component may be “the real thing” or

an unannounced drill, but can also be

done in a non-contiguous way. The

University of Pittsburgh Medical

Center, for example, validates the

training of their microbiology

technicians by occasionally submitting

a slide containing a biological pathogen

among normal slide sets. The objective

is to validate the ability of the

technician to identify the pathogen and

respond in an appropriate manner.

The non-contiguous training program

will be published by AHRQ. Until that

time, additional information is available

from Project Director Lucy Savitz,

Ph.D., at the Research Triangle

Institute: savitz@rti.org. 

Preparing Volunteer

Nurses for Public

Health Emergencies

With support from an AHRQ grant, the

Vanderbilt University School of

Nursing is developing and will evaluate

modules that are intended to prepare

volunteer and non-active nurses to

respond to events of bioterrorism or

other public health emergencies. The

evaluation will compare online with

face-to-face training to determine the

effectiveness and efficiency of each

approach. The project will also attempt

to define user characteristics that

predict selection and completion of

training by each method, and to

determine the adequacy of technology

integration in learning emergency

response skills. 

The project is targeted at inactive

nurses who have volunteered for the

Medical Reserve Corps (MRC) in their

local communities. MRC volunteers

must be trained to know what their role

is in an organized response to a mass

casualty event. The Vanderbilt project

will provide that training. Furthermore,

the Vanderbilt team believes that nurses

who have volunteered will be more

motivated to learn.

The training modules that are being

developed under the project are based

on competencies created by the

International Nursing Coalition for

Mass Casualty Education (INCMCE),

which is hosted by the Vanderbilt

University School of Nursing. Those

competencies are now available on the

INCMCE Web site, www.incmce.org. 

The first module is called “The Tipping

Point,” because a large public health

emergency may require value shifts. For

example, the nurse’s traditional approach

to triage may need to change. A mass

casualty event requires that the triage

nurse’s decisions must be based on what

will do the most good for the greatest

number of people. Thus, the critically ill

person may not be the one who should

be treated first—a value shift. 

Each of what will ultimately be seven

modules will be posted on the INCMCE

Web site as they become available. 

Discussion 

Following the presentations the

audience was invited to submit

questions to the panelists. Five major

subjects emerged from the ensuing

discussion. 

Sources of Information About

Competencies

In addition to the nursing competency

for mass casualty education, other

competencies have been developed by

several professional organizations. Also,

CDC has sponsored the development of

competency sets for public health. A

listing of Web sites where competencies

can be found is provided as part of this

issue brief. 
5

Public Health Emergencies

Other than Bioterrorism

One question raised was whether surge

capacity education and training was

being approached from a total health

perspective, with the range of

microorganisms and infectious diseases

that health care workers may face. 

Michael Allswede responded by

describing the “trifurcated response”

disaster plan at the University of

Pittsburgh Medical Center (UPMC).

The trauma response maximizes

personnel, equipment, beds, and

medications, all concentrated on

victims, or the emergency department.

The hazmat response starts with the

fundamental understanding that

something bad has happened outside

the hospital and must be kept outside

the hospital; this applies to a chemical

event or a radiation event. The

quarantine response involves

configuring the hospital to take in

potentially infectious or hazardous

patients by segregating staff and

contaminated patients from noncontaminated patients. 

Joan Cioffi noted that CDC’s dual

strategy of “just in case” and “just in

time” applies not just to a potential

bioterrorism event, but has been proved

to be effective in response to recent

outbreaks of SARS and monkey pox

and the potential of avian flu. Betsy

Weiner pointed out that the broader

term to describe the response to a mass

casualty incident is an “all-hazards”

approach.

Competency-based Training

In response to a question about

decontamination training, Michael

Allswede described how UPMC has

moved from time-based to objectivebased, or competency-based, training.

UPMC started with the Occupational

Safety and Health Administration’s

certified four-hour, eight-hour sequence

for decontamination training. That

approach was useful for familiarization

with the decontamination system, but

did not necessarily demonstrate the

acquisition of actual skills. The

questions to be answered are: “Can you

or can you not get into your

decontamination suit in two minutes or

less? Can you or can you not operate

the decontamination system? Can you

or can you not, in a four-person team,

decontaminate one patient every six

minutes?” The answers to those

questions can be measured by

observation. When the desired skill

level is reached the hospital can be

confident that staff will be able to

respond to an actual emergency. 

Medical Reserve Corps

Vanderbilt’s use of nurses who had

volunteered for the Medical Reserve

Corps elicited additional information

about the MRC. Betsy Weiner

explained that each MRC unit is

configured according to the needs of

the community it serves. Thus units

may include expected professionals like

physicians, nurses, pharmacists, and

Emergency Medical Technicians, but

also veterinarians, for example, because

some infectious diseases may appear

first in animals. In addition, April Kidd

called from the National Office of the

Medical Reserve Corps to provide the

program’s Web site, where more

information can be found. That Web

site is www.medicalreservecorps.gov. 

Incident Command System

Another caller raised the issue of the

importance of incorporating the

Incident Command System and

incident management system principles

into the training modules that are being

developed. This includes creation of

integrated training opportunities among

health care, public safety, emergency

medical services, and other public health

entities as part of the team training

process. Betsy Weiner responded that,

indeed, one of the lessons learned in

development of the mass casualty

education modules for nurses was that

incident management system principles

had to be included at the outset. Mass

casualty response, she said, is a process

that must be well integrated. 

Michael Allswede, on the other hand,

pointed to the experience of the UPMC

Health System, which includes 20

hospitals and approximately 7,000

doctors. They have learned that the

hospital component of the Incident

Command System involves too many

people without enough decisionmaking

power. The UPMC Health System has

thus reduced the number of physicians

in the command center to three higherlevel people with better decisionmaking

power. 

“Can you or can you not get into your decontamination suit

in two minutes or less? Can you or can you not operate the

decontamination system? Can you or can you not, in a fourperson team, decontaminate one patient every six minutes?”
AHRQ Pub. No. 04-P028

October 2004

Conclusion

Stakeholders, including decision

makers at the Federal, State, and local

levels; health system emergency

planners; and providers, all have an

essential role in ensuring sufficient

surge capacity within their

communities and regions. To guarantee

a rapid response in the event of a

public health emergency, they must

have sufficient staff available to

respond, and those staff must

understand their roles and perform

them effectively. Workforce education

and training—including the

competency-based training approach

described in this issue brief—will be

critical to ensuring health systems’

successful response to significantly

increased surge capacity requirements.

For More Information

The complete audioconference on

“Surge Capacity—Education and

Training for a Qualified Workforce”is

available as a streaming presentation

and as a text transcript on the 

AHRQ Web site

(www.ahrq.gov/browse/bioterbr.htm). 

This issue brief was prepared for 

AHRQ by AcademyHealth under 

contract number 290-98-0003.

Additional Resources Related to Bioterrorism, Surge Capacity, and

Health System Preparedness

www.hsrnet.net/ahrq/surgecapacity/event1 This site provides a helpful compilation of resources on 

/materials/competency_training.htm competency-based training for bioterrorism and other public

health emergencies.

www.mailman.hs.columbia.edu/CPHP/cdc/ This address leads to a Columbia University School of Nursing

COMPETENCIES.pdf publication on using core competencies: Core Public Health Worker 

Competencies for Emergency Preparedness and Response, Center for 

Health Policy, Columbia University School of Nursing, April 2001.

www.nursing.hs.columbia.edu/institute-centers/ This link offers a CDC brochure for all public health workers on core

chphsr/btcomps.pdf competencies related to bioterrorism and emergency. This link offers

a CDC brochure for all public health workers readiness.

http://cpmcnet.columbia.edu/dept/sph/CPHP/ This link leads to a brochure describing emergency preparedness

hospcomps.pdf and response competencies for hospital workers.

www.incmce.org/competenciespage.html The INCMCE Web site offers a description of educational 

needed by registered nurses responding to mass casualty incidents.

www.hrsa.gov/bioterrorism.htm HRSA’s Web site provides information on the National 

Bioterrorism Hospital Preparedness Program including 

detailed guidance on HRSA’s regional surge capacity benchmarks.

www.medicalreservecorps.gov The Medical Reserve Corps’ Web site offers information on its

mission and activities, including access to a listserv for MRC 

communities.

Source: These resources were referenced during the March 2, 2004 Web-assisted audio conference conducted by AHRQ:

“Surge Capacity: Education and Training for a Qualified Workforce.” Some Web sites may require Adobe®Acrobat® 6.0.