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

A bioterrorist attack from a biological,

chemical, or radiological agent, as well as

emerging new epidemics such as severe

acute respiratory syndrome (SARS), are

significant threats to public health in the

United States. Yet most hospitals lack

adequate beds, equipment, isolation

facilities, and staff to respond to a largescale bioterrorist attack or other public

health emergency. During these crises,

hospitals will have to convert quickly from

their current care capacity to surge

capacity—that is, the maximum patient

load a hospital or medical system can

handle.

A June 2003 Web-assisted audioconference sponsored by the Agency for

Healthcare Research and Quality (AHRQ)

focused on surge capacity assessment and

regionalization of resources to respond to

large numbers of people requiring

immunization, treatment, or quarantine;

the event was aimed at local, State, and

health systems policymakers. Panelists

included:

s Commander Brad Austin, M.P.H.,

Hospital Bioterrorism Preparedness

Program, Health Resources and

Services Administration (HRSA); 

s Michael Allswede, D.O., University of

Pittsburgh Medical Center Health

System;

s Stephen Cantrill, M.D., Denver Health

Medical Center; and 

s Dena Bravata, M.D., M.S., Project

Director of the Stanford–University of

California San Francisco (UCSF)

Evidence-based Practice Center.

The audio conference also included a

question and answer period, during which

listeners were invited to submit questions

to the panelists. 

This issue brief examines tools that can

assist hospitals and other health care

facilities to assess their current capacity

and develop a plan to achieve surge

capacity. A companion issue brief, titled

“Optimizing Surge Capacity: Regional

Efforts in Bioterrorism Readiness,”

examines how to develop regional

strategies to mobilize public health

emergency resources; it is available at

www.ahrq.gov.

U.S. Department of Health 

and Human Services

Public Health Service

Bioterrorism

and Health System Preparedness

Issue Brief

Optimizing Surge Capacity:

Hospital Assessment and Planning

No. 3
Benchmarks for Surge

Capacity

“In the event of a bioterrorist attack,

we must prepare for an overwhelming

number of patients,” said Commander

Brad Austin. “Therefore, it’s very

important for hospitals—emergency

departments in particular—and the

health care system as a whole to have

a good idea of their maximum

capacity and to plan how to respond to

a major public health emergency.” 

HRSA has set a critical benchmark for

all States to establish a system that

allows for the triage, treatment, and

disposition of 500 adult and pediatric

patients per 1 million population who

suffer from acute illness or trauma

requiring hospitalization from a

biological, chemical, radiological, or

explosive terrorist incident. HRSA

also requires that States establish a

response system that allows for the

immediate deployment of 250 or more

additional patient care personnel per

million population in urban areas, and

125 or more additional personnel per

million in rural areas. For the entire set

of HRSA requirements for

bioterrorism preparedness, please visit

www.hrsa.gov and click on “Focus on

Bioterrorism.” 

Hospital leaders who want to assess

their institution’s surge capacity may

find the Rocky Mountain Regional

Care Model for Bioterrorism Events

(RMBT), which has set staffing and

equipment benchmarks based on a 50-

bed unit, a useful guide

(www.denverhealth.org/bioterror). 

Converting Current

Capacity to Surge

Capacity

Converting a hospital or hospital

system’s current capacity into surge

capacity, often within 6 to 12 hours, is

a daunting task. Every day, hospital

leaders must be prepared to receive

large numbers of patients and plan to

ensure a sufficient supply of

ventilators, oxygen, medications,

vaccines, personal protective

equipment, and other supplies, as well

as medical staff. They must also think

through how to accommodate the

needs of vulnerable groups such as

children, the elderly, and the disabled.

Finally, they must make certain that

essential hospital services such as

food, water, and electricity are

continuously available and that they

are always able to rapidly

communicate with emergency medical

services and other regional support

services. 

In a recent presentation to the

Department of Health and Human

Service’s Secretary’s Council on

Public Health Preparedness, Lyman

Van Nostrand, M.P.A., Deputy

Director of HRSA’s Office of Planning

and Evaluation, suggested several

potential strategies for hospitals to

increase surge capacity. These are

listed below.

2

Potential Strategies for Increasing Hospital

Surge Capacity

s Discharge patients early; establish discharge holding area.

s Convert outpatient procedure beds into inpatient beds.

s Use hallways or create alternate treatment areas (e.g.,

cafeteria).

s Partner with local health department, emergency

management agency, Red Cross, to create emergency

treatment capacity outside the hospital.

- Initiate mutual agreements with other health care 

facilities.

- Include acute, long-term care, and rehabilitation 

facilities.

s Consider other local facilities such as schools, armories.

s Use automated surveillance and tracking systems.

s Link information from physicians, clinics, and hospitals

to the public health system and the first-responder

community.

s Implement communication systems to allow rapid

dissemination of information to key players and planners

in a mass-casualty event.
Determining the Type

of Hospital Action

“The fundamental challenge for public

policy in biodefense is to characterize

the threat itself,” said Michael

Allswede. He and Dr. Samuel Watson,

of the University of Pittsburgh

Graduate School of Public Health,

developed a tool called the Pittsburgh

Matrix to quantify the type and

magnitude of a health care system’s

response to a given bioterrorist event.

The Pittsburgh Matrix is based on the

idea that pathogen type, scale of

attack, and time of detection affect

hospital decisions such as the need to

stockpile antibiotics or set up isolation

units. This tool can be used to assess

medical preparedness for a variety of

potential scenarios and agents. For

example, some biological agents such

as smallpox warrant quarantine and

isolation, while others do not. Some

infectious agents are not amenable to

treatment, while others like anthrax

can be treated with several antibiotics.

For others, such as botulism, there is

an insufficient local supply of

botulinim antitoxin. 

“If you look at the matrix and rate

pathogens across the timeline, better

technology will move the response

earlier,” said Dr. Allswede. In turn,

better preparedness results in fewer

lives lost and at less cost. “For

example, if you’re going to save the

lives of victims of smallpox, which is

communicable and lethal, you use a

vaccination strategy in the pre-release

phase (within 4 days of exposure)

before people contract smallpox,” he

said. “After that it’s just containment.” 

The AHRQ Pittsburgh Matrix

workbook, “Workbook on Regional

Bioterrorism Preparedness,” can guide

other medical facilities. It is expected

to be available in January 2004 from

Lucy Savitz at savitz.rti.org.

Meeting the Special

Needs of Children

HRSA’s Emergency Medical Services

for Children Program was created to

ensure that the health care system can

meet the unique needs of children. Dr.

Michael Shannon is Chief of

Emergency Medicine at Children’s

Hospital Boston and Director of the

hospital’s newly created Center for

Biopreparedness. He said that during a

bioterrorist attack or other public

health emergency, the reactions of

children to agents may be more severe

than adults, and their limited ability to

communicate can complicate

diagnosis and treatment. The Center

for Biopreparedness has developed

protocols for pediatric surge capacity

and decontamination protocols for

pediatric victims of chemical or

radiation exposure. The Center is also

preparing a series of best practice

monographs on these and other topics

that will be available from AHRQ by

the summer of 2004. 

In addition, the Center will establish

guidelines for a pediatrics-focused

hazardous materials response that can

be used by emergency medical

responders, schools, neighborhood

health centers, community hospitals,

and parents. The Center will also

develop training protocols for

emergency department physicians and

staff, and continue to create syndromic

surveillance and reporting tools. One

such tool, called EDScope

(http://edscope.tch.harvard.edu/edscop

e/actvsfore.htm), identifies real-time

changes in the visit pattern of the

Boston Children’s Hospital Emergency

Department. 

Triage Challenges 

HRSA advises hospitals to work closely

with public health agencies, emergency

response networks, and others to

manage not only the acutely ill but also

the “worried well” individuals who are

uninfected but anxious that they may

have contracted a disease. Dena Bravata

remarked that, “Near ground zero at the

World Trade Center in New York, the

‘worried well’ far exceeded those

needing medical care.” To deal with the

acutely ill, hospitals should form

agreements with other medical sites, as

well as schools, hotels, or convention

centers, to establish off-site triage of

patients and off-site acute care. Two

recommendations were made for

dealing with the “worried well.” To

prevent an unnecessary surge of

worried well patients, Stephen Cantrill

stressed the importance of proper

communication of risk. Brad Austin

added that hospitals could interact with

local mental health systems to create a

system to take care of these individuals.

The University of Pittsburgh Medical

Center Health System has developed a

psychological SWAT team for the

acutely anxious, quarantined people

with cabin fever, and for staff (for

example, cooks or custodians) who

have become mutinous as a result of

misinformation. This approach is

briefly discussed in the “Workbook on

Regional Bioterrorism Preparedness”

(savitz.rti.org). 

3
Cost Considerations

HRSA funding ($518 million for fiscal

year 2003) for hospital bioterrorism

preparedness is expected to grow

substantially and then taper off, as

hospitals become better prepared.

Currently, the cost of caring for victims

of bioterrorism, and preparing to care

for them, are burdens for hospitals that

are already in a financial crisis. The

Pittsburgh Matrix incorporates cost

factors by calculating, for example, the

cost of antibiotic stockpiling, additional

staff, or other key resources in terms of

dollars per life saved for each public

health crisis scenario. The RMBT is

also set up to gauge the impact of

bioterrorist attacks and other public

health emergencies on hospital and

health system costs. 

Regional Resources 

No hospital or medical system can

manage a bioterrorist attack or other

public health emergency by itself. Each

hospital needs to identify and mobilize

regional resources to help manage the

crisis. The Stanford/UCSF Evidencebased Practice Center is currently

performing a comprehensive review of

the literature on the evidence to support

various methods of regionalization of

services for bioterrorism preparedness.

This Evidence Report will be available

from AHRQ by early 2004

(www.ahrq.gov).

For More Information

The audioconference on which this

issue brief is based, “Surge Capacity

Assessments and Regionalization

Issues,” is available as a streaming

presentation with text captioning on the

AHRQ Web site

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

Information on 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 it

becomes available. Please check the

Web site frequently.

This issue brief was prepared for AHRQ

by AcademyHealth under contract

number 290-98-0003.

AHRQ Pub. No. 04-P008

January 2004