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

Regional bioterrorism planning is critical

in the aftermath of the terrorist attacks of

September 11, 2001, and the anthrax

attacks that followed them. One hospital

working alone to prepare for a massive

influx of patients in the event of a public

health emergency or a bioterrorism attack

is not sufficient. Indeed, an entire

community by itself might not be able to

handle a public health emergency

involving mass casualties. When

developing plans to mobilize quickly,

hospitals need to look at resources both in

their communities and beyond.

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 regional

strategies to identify and mobilize

resources to respond to a public health

disaster such as a bioterrorist attack. A

companion issue brief, titled “Optimizing

Surge Capacity: Hospital Assessment and

Planning,” explores how hospitals can

assess their current capacity and convert it

into surge capacity; it is available at

www.ahrq.gov.

Understanding Surge

Capacity 

Given the threat of a bioterrorist attack,

infectious disease outbreak, or other

public health emergencies, hospitals must

U.S. Department of Health 

and Human Services

Public Health Service

Bioterrorism

and Health System Preparedness

Issue Brief

Optimizing Surge Capacity: Regional

Efforts in Bioterrorism Readiness

No. 4
prepare for an overwhelming number

of patients for either an acute period or

over an extended period of time. It is

important for the leaders of health care

institutions to think about surge

capacity as more than just the number

of available hospital beds. They need

to understand their capacity to handle

a public health emergency by

examining three categories of

resources within their own facilities:

beds, staffing, and equipment 

(Table 1). 

In addition, they should be

knowledgeable about pharmaceutical

caches in local pharmacies until

supplies are delivered from the

Strategic National Stockpile, and

should ensure that communications

and information technology are in

place to connect health care systems

components.

Addressing Surge

Capacity at the

Regional Level

Hospitals need to evaluate their surge

capacity not only within their own

facilities, but also within the context of

their communities and at the broader,

regional level. Hospitals must identify

State and local partners as well as

Federal representatives who can work

to ensure adequate staffing and bed

space in the event of a worst case

scenario. Health care facilities should

work with all potentially available

community resources, including

primary health clinics, Veterans

Administration hospitals, military

medical facilities, and Indian Health

Service facilities. “This approach will

allow the health system as a whole to

manage surge capacity,” said

Commander Austin.

In fiscal year 2003, HRSA’s National

Bioterrorism Hospital Preparedness

Program will award more than half a

billion dollars in the form of

cooperative agreements to public

health departments in States,

territories, and municipalities. The

purpose of this program is to upgrade

the preparedness of the Nation’s health

care system to respond to bioterrorism,

infectious disease outbreaks, and other

public health threats and emergencies. 

“We are tasking hospitals to look at

surge capacity from a broader regional

level,” said Commander Austin. The

definition of a region varies but should

accommodate the unique geography

and circumstances of an area. Some

States define regions using preexisting emergency aid regions, while

others use counties. Under the

Bioterrorism Hospital Preparedness

Program, HRSA provides surge

capacity benchmarks that it asks

recipients under this program to plan

for (Table 2). 

Stephen Cantrill identified several data

sources that can help regions

determine their baseline capacity, an

important first step in preparing for a

mass-casualty disaster (Table 3).

Denver Model for

Assessing Regional

Capacity

An example of a regional approach

that other areas can learn from is the

Rocky Mountain Regional Care Model

for Bioterrorist Events (RMBT). This

AHRQ-funded initiative is designed to

identify and address surge capacity

needs in the event of a bioterrorist

attack. The RMBT project is a

collaborative effort among six States

in Federal Region VIII (Colorado,

Montana, North Dakota, South

Dakota, Utah, and Wyoming), and

relies on the involvement of numerous

Federal, State, and local partners.

When completed, the RMBT project

will provide tools that other regions

2

Table 1. Surge Capacity—Categories of

Resources

Beds Emergency department beds, intensive 

care unit beds, general beds, mental 

health beds, and pediatric beds

Staffing Physicians, nurses, pharmacists, mental 

health professionals, emergency medical

technicians, public health professionals 

and others

Supplies and Pharmaceuticals, personal protective

Equipment equipment, portable and fixed

decontamination systems, isolation 

facilities, and rapid diagnostic systems
3

Table 2. HRSA Surge Capacity Benchmarks

Hospital beds Beds for 500 acutely ill patients requiring hospitalization from a 

bioterrorist incident per million population

Decontamination Adequate portable or fixed decontamination systems for 500

facility patients and workers per million population 

Negative pressure, At least one per health system must be able to support

HEPA-filtered 10 patients at a time

isolation facility

Health care Response system that allows immediate deployment of 250 

personnel additional personnel per million population in urban areas

System of 125 additional personnel per million in rural areas

Personal protective Adequate personal protection equipment for 250 additional health 

equipment care personnel per million population in urban areas

Adequate equipment for 125 additional personnel per million in 

rural areas

Table 3. Data Sources for Determining Baseline Capacity

Hospital data HRSA Hospital Needs Assessments provide information on hospital 

bioterrorism readiness by State. For more information go to 

www.hrsa.gov/bioterrorism.htm

American Hospital Association has regional facility data. For more 

information go to www.hospitalconnect.com

Bed data The National Disaster Medical System (NDMS) currently gathers 

available bed counts on a monthly basis. For more information contact

your local NDMS office or visit www.ndms.dhhs.gov. 

Staffing data State licensing boards for physicians, nurses, and emergency medical 

technicians. 

The American Medical Association also provides a database of health 

care personnel. For more information go to www.ama-assn.org
4

can use in their own surge capacity

planning. These tools include a

template that identifies staffing and

supply needs for a 50-bed acute care

unit. With these guidelines from the

RMBT project, such a unit could be

mobilized quickly. In addition, RMBT

is developing a medical armory

supply list that will be useful to other

regions. This list will describe nonperishable supplies such as beds and

intravenous poles that can be stored

now and transported when a disaster

occurs.

RMBT is also preparing criteria to

help communities identify alternate

care sites such as hotels and

gymnasiums to treat patients in case

hospitals are inundated with victims.

“We only have so many brick-andmortar hospitals,” said Stephen

Cantrill. “In a true bioterrorism event,

they would most likely be filled up

and health officials would need

criteria to identify other care sites.” 

Challenges in Rural

Areas 

Many rural hospitals have disaster

plans to manage natural catastrophes

such as floods, earthquakes, and

hurricanes, but few develop strategies

that take into consideration an attack

involving biological agents. While the

threat of a terrorist attack occurring in

rural America may seem remote,

many of these areas are home to

power plants, hydroelectric dams,

military bases, and other potential

terrorist targets. 

Hospitals in rural areas are typically

small and resource-strapped, and thus

are likely to find it difficult to address

surge capacity needs. “Staffing issues

are much more pronounced in rural

areas,” said Dr. Cantrill. “Rural

hospital closings have exacerbated the

situation.” Rural communities rely on

volunteer emergency responders,

many of whom serve in multiple roles.

Primary care is delivered by

community health centers and isolated

practitioners who lack disaster

training. Insufficient emergency

equipment and communication

systems pose additional problems.

Despite these challenges, rural areas

must undertake many of the same

emergency preparedness activities as

more populated regions. Readiness

assessments funded by HRSA in 2002

were the first step in these activities.

HRSA’s Bioterrorism Hospital

Preparedness Program will enable

many rural areas to improve their

capacity to respond to bioterrorism

and other public health emergencies.

In addition, rural hospitals that belong

to the American Hospital Association

can find resources, including a Rural

Hospital Disaster Readiness report, at

www.hospitalconnect.com. Rural

providers also need to actively

participate in disaster drills in order to

detect deficiencies in regional

planning. Distance learning will be an

important means of offering disaster

training to rural emergency responders

and primary care providers. 

Best Practices in

Regional Response 

Hospital planners and public health

officials—whether urban or rural—

can learn from responses to past

disasters. The Stanford–UCSF

Evidence-based Practice Center is

preparing a report that synthesizes the

evidence about efforts to coordinate

emergency response services within

regions. The report examines regional

responses to public health

emergencies such as the anthrax cases

and the Severe Acute Respiratory

Syndrome outbreak. Because there are

few terrorist incidents to draw from,

the report also includes the evidence

about regionalized responses to

natural disasters such as hurricanes

and earthquakes. 

The Evidence Report will document

the key tasks that were required to

mount a response to each of these

events. The report will also catalogue

the relevant resources, such as

personnel and supplies, needed to

perform each task. When the report is

completed, public health officials and

emergency management professionals

will be able to review best practices

for performing key emergency

response tasks such as surveillance.

They will also be able to use it to

identify other response organizations

in their regions. The report will be

available from AHRQ by early 2004

(www.ahrq.gov).

Dena Bravata, Project Director at the

Evidence-based Practice Center, said

the report will draw lessons from the

established logistics practices of

companies such as Hewlett Packard,

Walmart, and Eastman-Kodak. “These

companies have implemented costeffective supply chains for the

manufacture and distribution of goods

and services to retailers and eventually

to customers,” she said. “The

challenge of acquiring, storing,

distributing, and dispensing

antibiotics, vaccines, and other

essential materials for a bioterrorism
5

response is similar.” Programs such as

the Strategic National Stockpile and the

Laboratory Response Network also

offer lessons in regional supply and

resource management.

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.

The Laboratory Response Network is an informal

partnership that organizes laboratory resources in the

event of a bioterrorism attack or public health emergency

involving chemicals. The network classifies laboratories

from Level A facilities that do routine clinical testing to

Level D labs that have containment equipment and

expertise to respond to the most dangerous pathogens

such as smallpox. Level D labs include only Centers for

Disease Control and Prevention and Department of

Defense labs, FBI labs, and the U.S. Army Medical

Research Institute of Infectious Diseases.

The Strategic National Stockpile (SNS) (formerly

known as the National Pharmaceutical Stockpile)

ensures the availability of life-saving pharmaceuticals,

vaccines, antidotes, and other medical supplies and

equipment necessary to counter the effects of nerve

agents, biological pathogens, and chemical agents. The

SNS augments State and local supplies of

pharmaceuticals, vaccines, and medical supplies during

responses to emergencies. These packages are stored in

strategic locations across the country to ensure rapid

delivery to the local dispensing sites. State and local

officials across the country are developing and testing

plans to rapidly dispense the supplies from the SNS to

their populations. 
AHRQ Pub. No. 04-P009

January 2004