www.ahrq.gov 

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.

Introduction

Biological terrorism, or bioterrorism,

presents a significant public health threat

to the United States. Hospitals across the

country are engaged in disaster planning

activities to prepare for such a threat.

While bioterrorism preparedness is in its

infancy, several tools are available and

more are being developed to assist

hospital disaster planners.

Some of these tools were featured in an

April 2003 Web-assisted audioconference

sponsored by the Agency for Healthcare

Research and Quality (AHRQ) and aimed

at hospital and public health officials.

Presentations were made by the following

researchers and practitioners: 

s Gary B. Green, M.D., M.P.H., FACEP,

The Johns Hopkins University School

of Medicine, Baltimore, Maryland; 

s Mary Massey, Anaheim Memorial

Medical Center, Anaheim, California;

and

s Howard W. Levitin, M.D., FACEP,

Disaster Planning International,

Indianapolis, Indiana; and Sue

Skidmore, Booz-Allen & Hamilton,

McLean, Virginia.

The audioconference also included a

question and answer period, during which

listeners were invited to submit questions

to the panelists.

This issue brief examines resources that

can assist hospitals and other health

systems in preparing for bioterrorism

disasters, and in conducting disaster drills

in particular. Disaster drills are an

important tool to improve local disaster

response. They are exercises designed to

test the response of the health care system

during mass-casualty emergencies by

recreating a disaster situation using mock

victims, theoretical scenarios, or computer

simulations. 

Conventional Disasters

versus Bioterrorism 

Preparedness for “conventional”

disasters—such as earthquakes, floods,

major accidents, and fires—is the

foundation for bioterrorism readiness. The

basic components of an adequate disaster

response system have been defined, and

the steps necessary to build disaster

preparedness capacity have been

established. If health care institutions have

put all the pieces in place for general

disaster preparedness, they will have taken

U.S. Department of Health 

and Human Services

Public Health Service

Bioterrorism

and Health System Preparedness

Disaster Planning Drills and

Readiness Assessment

Issue Brief

No. 2
the first and most important step

toward preparedness for responding to

a bioterrorist event.

What would distinguish the health

system response to a bioterrorist event

from the response to a conventional

disaster is the additional knowledge,

skills, and resources needed in the

event of a bioterrorist attack.

Bioterrorism is broadly defined to

include terrorist use of biological

agents such as anthrax, smallpox,

botulism, and plague. In the event of a

bioterrorism disaster, additional tasks

for hospitals would include: 

s Decontaminating victims;

s Protecting health care workers

from infection; 

s Containing infectious agents; and

s Using treatments specific to

biological agents. 

Another distinguishing characteristic

to be expected from a bioterrorism

event would be its broader impact on

the health care system. Dr. Howard

Levitin pointed out that, whereas in a

natural disaster the vast majority of

victims come to the emergency room,

are treated, and released, in a

bioterrorist event people would

become ill and would have to be

admitted to the hospital for longer

term care. This would affect hospital

staffing and inpatient and outpatient

capacity. Mary Massey noted another

special problem to be prepared for: the

fear factor. She added that the most

effective way to counter the public’s

fear is to provide information that is

consistent and consistently worded,

whether it comes from the local

Emergency Medical Service, the

public health department, or the

Federal Centers for Disease Control

and Prevention.

Disaster Planning: An

Ongoing Community

Effort

Continuous Effort

Disaster planners should view

bioterrorism preparedness efforts as an

ongoing quality improvement

initiative. “An institution never reaches

a total state of preparedness,” said

Green. He encouraged hospitals to

view disaster preparedness efforts as

part of a “continuous cycle.” Within

this ongoing process, hospitals should

undertake a number of steps to ensure

that they are adequately prepared, as

shown below.

The steps in the cycle can be applied

at the departmental level, at the

institution level, community level, and

on up to the regional level.

Key Components

By its very nature, disaster response is

complex and confusing. Most planners

agree, however, that an adequate

disaster response system must include

several key components: 

s Incident Command System

(ICS)—Also referred to as a

“command and control” function,

the ICS defines roles and

responsibilities of all disaster

response participants; 

s System integration—Largely

communication capability.

2

The Continuous Cycle of Disaster

Preparedness

s Assemble an interdisciplinary team of key stakeholders

for disaster planning;

s Review current resources, strengths, and weaknesses;

s Develop a detailed, written disaster response plan;

s Disseminate and practice the plan through education and

drills;

s Evaluate the adequacy of knowledge, skills, and

resources;

s Revise the plan based on objective data and lessons

learned;

s Modify education and training as needed to target areas

of weakness; and

s Continuously repeat these steps.
Hospitals must integrate response

functions within their facilities and

coordinate efforts with outside

agencies; 

s Logistics—Includes a supply

management system, plan for

facilities use, and system for

transporting patients, providers,

and materials; 

s Security—Critical to enable the

other components to operate the

way they are intended to; 

s Clinical care;

s Human resources; and

s Public relations. 

Individual health care institutions may

also categorize other components

according to their needs.

Community-Wide Plan

Mary Massey, Disaster Coordinator at

Anaheim Memorial Medical Center,

stressed the importance of a

community-wide plan. “We are all

used to emergency preparedness

within our own organizations,” she

said. “What hospitals need to do is

develop an integrated community

response.” For example, hospitals

should work with local agencies to

define roles and responsibilities in the

event of a disaster and to create

redundant communication systems. A

veteran of many drills, Massey

stressed the importance of “bringing

all the community players together”:

law enforcement, fire departments,

emergency medical services, public

health officials, community health care

providers, and local industries. “This

isn’t a battle to see which agency is

best; this is a battle to prepare your

community.”

Hospital Emergency Incident

Command System (HEICS)

One important resource available to

disaster planners is the Hospital

Emergency Incident Command

System (HEICS), an emergency

management system developed first by

Orange County and later revised by

the San Mateo County Health Services

Agency of California. Now used by

hospitals across the country, HEICS

lays out a logical management

structure, clear responsibilities and

reporting channels, and a common

terminology to help hospitals and

emergency responders communicate in

the event of a disaster. Available free

of charge, HEICS may be downloaded

from the California Emergency

Medical Services Authority Web site

(www.emsa.ca.gov/dms2/heics3.htm).

Disaster Training and

Evaluation

Training Techniques

Dr. Green and his colleagues at the

Johns Hopkins University Evidencebased Practice Center (EPC) have

conducted a study, funded by AHRQ,

to identify and review data on the most

effective ways to train clinicians to

respond to a bioterrorist attack or other

public health event that poses similar

challenges to the health care system.

The study identified several different

training techniques: 

s Traditional educational methods.

These include lectures,

discussions, audiovisuals, and

written materials. 

s Teleconferencing. This approach

can reach a larger audience and

appears to be as effective as

classroom learning.

s “Smart” patients or mock

victims. Such individuals are

helpful for one-on-one training, but

less practical for training large

numbers.

s “Tabletop” exercises. Theoretical,

“paper” drills do not require

physical movement of patients,

personnel, or equipment. They

usually focus on the ICS and

system integration components.

Tabletop exercises appear to be

useful but might be most effective

when combined with other

teaching approaches.

s Computer simulations. Simulated

drills can potentially replace

expensive drills and identify

weaknesses in disaster planning.

s Disaster drills. Physical drills

improve knowledge of the disaster

plan and highlight weaknesses.

Little standardization of such drills

exists, however.

While little data exist to indicate which

training approaches work best or

which are most cost effective, most

planners agree that their success

3

“There is no cookbook

recipe that every

institution can follow that

can lead to adequate

preparedness.” 

Gary B. Green, The Johns Hopkins

University School of Medicine
4

depends on practice. “You can have

the best plans and policies in the

world,” said Massey, “but without

communication and training they sit

on the shelf and never get used.” 

Conducting Drills

Drills are one of the most commonly

used disaster training techniques.

Experience from the field offers

several lessons. First, hospitals should

carefully consider the parameters of a

drill and make basic decisions about

its evaluation, said Green. It is

important to have a detailed evaluation

plan in place before the drill begins.

What are the specific goals for a

particular drill? What are the

“borders” of the drill—will it

encompass the entire hospital or just

the emergency department? Will it

include supplies? Will it include

pharmacy? What about radiology?

Which components of the drill will

the hospital evaluate? What evaluation

tools will the hospital use? 

Controlling the end of a disaster drill

is difficult from an operational

perspective and requires a distinct

plan to avoid confusion and loss of

data. Hospitals should conduct a

debriefing with all players involved

immediately following any drill. Such

a meeting allows participants to

process the drill and offers lessons for

future training. 

Evaluating Drills

While disaster drills are critical to

improving medical response in the

event of a disaster, no standard

methodology exists to evaluate the

effectiveness of a drill. Dr. Green and

his colleagues at the Johns Hopkins

EPC are developing a set of data

collection instruments for assessment

of disaster drills. To maximize

flexibility, the instruments are being

developed in modules so that users

can choose the components they need

to evaluate their particular drills. The

set includes modules for the incident

command system, triage,

decontamination, in-hospital treatment

centers, and post-drill debriefing.

After expert panel review and field

testing, they are expected to be

available by the end of 2003, and will

be posted on the AHRQ Web site

(www.ahrq.gov). 

Readiness

Assessment for

Hospitals 

One of the original bioterrorism

preparedness studies funded by

AHRQ in 2000 included the

development of the “Bioterrorism

Emergency Planning and

Preparedness Questionnaire for

Healthcare Facilities.” The study is

being conducted by Booz Allen

Hamilton, working with Dr. Howard

Levitin of Disaster Planning

International. In the first phase of the

study, the Booz-Allen team examined

several assessment tools and

preparedness questionnaires, most of

which emphasized management of

specific biological agents rather than

broader planning issues. The

researchers also found that there were

no nationally accepted benchmarks of

adequate preparedness, and that there

was no mechanism in place to share

best practices or useful solutions. 

The research team developed a

bioterrorism preparedness

questionnaire for health care facilities

to help those facilities assess their

capacity to respond to and treat the

victims of a biological incident. The

survey addresses topics such as

biological weapons training for

hospital personnel, hospital staffing,

ability to increase inpatient and

outpatient treatment capacity,

availability of equipment and supplies,

internal and external communications,

stockpiling of antibiotics, and

laboratory capability. The first-phase

questionnaire is available on AHRQ’s

Web site.

In the second phase of the study, the

Booz-Allen team is developing

objective measures to interpret the

results of the questionnaire, will

develop planning templates, and will

identify best practices. The team is

also working with a panel of experts

and a survey design firm to revise the

questionnaire. The revised

questionnaire will have 12 categories: 

s Regional linkages;

s Bioterrorism planning and

structure;

s Training and exercise;

s Triage, diagnosis, and treatment;

s Infection control,

decontamination, and isolation;

s Public health surveillance; 

s Surge capacity and space

utilization;

s Laboratories;

s Pharmacies and mass

immunization; 

s Safety and psychiatric support;

s Information systems; and

s Public relations. 
5

These categories are consistent with the

Health Resources and Services

Administration (HRSA) priorities,

which will help grantees to benchmark

their level of preparedness under the

guidelines of the National Hospital

Bioterrorism Preparedness Program.

The questionnaire is to be field-tested

with HRSA grantees.

“Along with the revised questionnaire,

we will provide the objective measures

that hospitals need to interpret the

results of the questionnaire,” said Sue

Skidmore of Booz Allen Hamilton,

principal investigator for the project.

“In other words, we’ll let them know

where they fall on a continuum of

bioterrorism preparedness.” Ultimately,

the agency hopes that these tools will

help hospital and health systems

planners to communicate better medical

resource needs in the event of a

bioterrorist attack or other disaster.

For More Information

The complete audioconference on

“Disaster Drills and Readiness

Assessment” is available as a streaming

presentation and as a text transcript on

the AHRQ Web site

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

The Johns Hopkins Evidence Report,

Training of Clinicians for Public Health

Events Relevant to Bioterrorism

Preparedness, is available on the

AHRQ Web site and through the

AHRQ Clearinghouse (call 1-800-358-

9295 or order electronically at

ahrqpubs@ahrq.gov; request AHRQ

Publication No. 02-E011).

The tools discussed in this issue brief,

and other tools and publications related

to health system preparedness for

bioterrorism, will be posted on the

AHRQ Web site as they become

available. Please check the Web site

frequently. 

This issue brief was prepared for AHRQ

by AcademyHealth under contract

number 290-98-0003.

Basic Components 

of Disaster Response

System

s Incident Command System

(ICS) 

s System integration

s Logistics

s Security

s Clinical care

s Human resources

s Public relations 

Anaheim Memorial Medical Center’s Mary Massey reflects on 

her experience in planning and conducting disaster drills.

s It’s O.K. to make mistakes. At first we took it very personally if we made any mistakes.

Over time we realized that a perfect drill wasn’t possible and that errors presented

opportunities to learn.

s Make it as real as possible. Don’t just practice with key players who already know how

it should work. Get real people working as victims. Ask the community to get involved

as victim volunteers. 

s Make it fun. Take lots of pictures. Laugh at yourselves. Remember, the goal is to find a

way of taking care of you and your community, not to make the prettiest, most perfect

disaster drill that has ever happened. 
AHRQ Pub. No. 04-P007

January 2004