```

[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]

 
   IS THE MEDICAL COMMUNITY READY IF DISASTER OR TERRORISM STRIKES: 
               CLOSING THE GAP IN MEDICAL SURGE CAPACITY

=======================================================================

                             FIELD HEARING

                               before the

                      SUBCOMMITTEE ON MANAGEMENT,

                     INVESTIGATIONS, AND OVERSIGHT

                                 of the

                     COMMITTEE ON HOMELAND SECURITY

                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                            JANUARY 25, 2010

                               __________

                           Serial No. 111-50

                               __________

       Printed for the use of the Committee on Homeland Security
                                     

[GRAPHIC] [TIFF OMITTED] 

                                     

      Available via the World Wide Web: http://www.gpo.gov/fdsys/

                               __________

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20402-0001

                     COMMITTEE ON HOMELAND SECURITY

               Bennie G. Thompson, Mississippi, Chairman

Loretta Sanchez, California          Peter T. King, New York
Jane Harman, California              Lamar Smith, Texas
Peter A. DeFazio, Oregon             Mark E. Souder, Indiana
Eleanor Holmes Norton, District of   Daniel E. Lungren, California
Columbia                             Mike Rogers, Alabama
Zoe Lofgren, California              Michael T. McCaul, Texas
Sheila Jackson Lee, Texas            Charles W. Dent, Pennsylvania
Henry Cuellar, Texas                 Gus M. Bilirakis, Florida
Christopher P. Carney, Pennsylvania  Paul C. Broun, Georgia
Yvette D. Clarke, New York           Candice S. Miller, Michigan
Laura Richardson, California         Pete Olson, Texas
Ann Kirkpatrick, Arizona             Anh ``Joseph'' Cao, Louisiana
Ben Ray Lujan, New Mexico            Steve Austria, Ohio
William L. Owens, New York
Bill Pascrell, Jr., New Jersey
Emmanuel Cleaver, Missouri
Al Green, Texas
James A. Himes, U.S. Virgin Islands
Mary Jo Kilroy, Ohio
Eric J.J. Massa, New York
Dana Titus, Nevada

                    I. Lanier Avant, Staff Director

                     Rosaline Cohen, Chief Counsel

                     Michael Twinchek, Chief Clerk

                Robert O'Connor, Minority Staff Director

                                 ______

       SUBCOMMITTEE ON MANAGEMENT, INVESTIGATIONS, AND OVERSIGHT

             Christopher P. Carney, Pennsylvania, Chairman

Peter A. DeFazio, Oregon             Gus M. Bilirakis, Florida
Bill Pascrell, Jr., New Jersey       Anh ``Joseph'' Cao, Louisiana
Al Green, Texas                      Daniel E. Lungren, California
Mary Jo Kilroy, Ohio                 Peter T. King, New York (Ex 
Bennie G. Thompson, Mississippi (Ex  Officio)
Officio)

                   Tamla T. Scott, Director & Counsel

                          Nikki Hadder, Clerk

                    Michael Russell, Senior Counsel

               Kerry Kinirons, Minority Subcommittee Lead

                                  (II)

                            C O N T E N T S

                              ----------                              
                                                                   Page

                               Statements

The Honorable Christopher P. Carney, a Representative in Congress 
  From the State of Pennsylvania, and Chairman, Subcommittee on 
  Management, Investigations, and Oversight......................     1
The Honorable Gus M. Bilirakis, a Representative in Congress From 
  the State of Florida, and Ranking Member, Subcommittee on 
  Management, Investigations, and Oversight......................     2

                                Panel I

Dr. B. Tilman Jolly, Associate Chief Medical Officer for Medical 
  Readiness, Department of Homeland Security:
  Oral Statement.................................................     5
  Prepared Statement.............................................     6
Dr. Gregg A. Pane, Director, National Health Care Preparedness 
  Programs, Office of Preparedness and Emergency Operations, 
  Office of the Assistant Secretary for Preparedness and 
  Response, Department of Health and Human Services:
  Oral Statement.................................................     8
  Prepared Statement.............................................    10
Ms. Shannon Fitzgerald, Director, Pennsylvania Office of Public 
  Health Preparedness, Pennsylvania Department of Health:
  Oral Statement.................................................    15
  Prepared Statement.............................................    17
Ms. Cynthia A. Bascetta, Director, Health Care, Government 
  Accountability Office:
  Oral Statement.................................................    20
  Prepared Statement.............................................    22

                                Panel II

Dr. John J. Skiendzielewski, Director, Emergency Medicine 
  Services, Geisinger Medical Center, Danville, Pennsylvania:
  Oral Statement.................................................    46
  Prepared Statement.............................................    47
Mr. Michael N. O'Keefe, President and Chief Executive Officer, 
  Evangelical Community Hospital, Lewisburg, Pennsylvania:
  Oral Statement.................................................    50
  Prepared Statement.............................................    52
Mr. Robert A. Kane, Jr., Vice President of Operations, 
  Susquehanna Health, Williamsport, Pennsylvania:
  Oral Statement.................................................    54
  Prepared Statement.............................................    56
Mr. Gary A. Carnes, President and Chief Executive Officer, All 
  Children's Health System, St. Petersburg, Florida:
  Oral Statement.................................................    58
  Prepared Statement.............................................    59

                             For the Record

The Honorable Christopher P. Carney, a Representative in Congress 
  From the State of Pennsylvania, and Chairman, Subcommittee on 
  Management, Investigations, and Oversight:
  Statement of The Hospital & Healthsystem Association of 
    Pennsylvania.................................................    44

   IS THE MEDICAL COMMUNITY READY IF DISASTER OR TERRORISM STRIKES: 
               CLOSING THE GAP IN MEDICAL SURGE CAPACITY

                              ----------                              

                        Monday, January 25, 2010

             U.S. House of Representatives,
                    Committee on Homeland Security,
 Subcommittee on Management, Investigations, and Oversight,
                                                      Danville, PA.
    The subcommittee met, pursuant to call, at 11:05 a.m., at 
Danville Borough Council Hall, Danville, Pennsylvania, Hon. 
Christopher P. Carney [Chairman of the subcommittee] presiding.
    Present: Representatives Carney, Bilirakis.
    Mr. Carney. The Subcommittee on Management, Investigations, 
and Oversight will come to order. The subcommittee is meeting 
today to receive testimony on ``Is the Medical Community Ready 
if Disaster or Terrorism Strikes: Closing the Gap in Medical 
Surge Capacity.'' First, I would like to thank everyone for 
joining us today. I would especially like to thank our Ranking 
Member, Mr. Bilirakis, from Florida. Gus, this is as warm as we 
could make it in Pennsylvania in January. I am also honored 
that so many Federal and State experts were able to join us, 
and I am extremely proud that so many of our outstanding local 
hospitals are able to participate in today's hearing.
    Today, we will examine how the Department of Homeland 
Security coordinates the Department of Health and Human 
Services, local hospital facilities, and public health 
officials in establishing and coordinating a National medical 
response strategy during an act of terrorism or public health 
threat, including biological, chemical, or a radiological 
event. It is my hope that this hearing will yield a clear 
vision of how hospital systems located in rural communities 
throughout the country receive vital information from Federal 
and State government partners leading up to and during natural 
or man-made disasters, and whether the plan that is currently 
in place meets their needs.
    The need to surge medically is widely recognized as being 
necessary and the goals for increasing medical surge capacity 
have long been established, but the ability for any hospital or 
other health care delivery establishment in the United States 
to do so is difficult. This is because health care delivery 
programs are required to create the greatest amount of 
efficiency with the least amount of waste while medical 
preparedness activities demand that resources be stored in 
advance of an event, thereby decreasing efficiency and 
intentionally leaving resources unused.
    Hospitals often wind up sacrificing the future for the 
present especially given the current state of the economy. 
Further, when grant programs provide little funding to cover 
preparedness activities, preparedness quite literally does not 
pay in the health care delivery system. We must, however, 
ensure that every effort is made to prevent as much illness and 
save as many lives as possible when large scale disasters and 
acts of terrorism occur. We need only to look at the situation 
in Haiti to see how important medical surge capacity and 
preparedness is. It is imperative that we identify areas that 
are still in need of additional resources and more focused 
Congressional oversight is required.
    In addition to the Commonwealth of Pennsylvania, efforts in 
other States and territories should be characterized and 
compared in order to better understand how to increase medical 
surge capacity without negatively affecting profit margins. 
Different sectors must partner with each other. When trusted 
relationships are established information and resources are 
shared to a much greater extent. Efforts need to be both 
coordinated and integrated. Public health and health care 
resources are limited so the efforts of these sectors need to 
be as efficient as possible.
    Finally, standard of care decisions need to be made now on 
what to do when the number of patients needing treatment far 
exceeds the number of resources available to treat them. I 
would like to thank all the witnesses for their participation. 
I look forward to their testimony. I would also like to thank 
the Hospital and Healthsystem Association of Pennsylvania, 
which was kind enough to submit written testimony for the 
record. The Chair now recognizes the Ranking Member of the 
subcommittee, the gentleman from Florida, Mr. Bilirakis, for 
his opening statement.
    Mr. Bilirakis. Thanks, Chris. I am happy to be here in the 
district to consider the issue of medical surge capacity, and I 
will tell you even though I am from Florida, my dad is from 
Western Pennsylvania, a town called Clairton, and I love this 
State. You always have a friend in Pennsylvania. Of course, I 
root for the Pirates and the Steelers. Whether we are talking 
about urban, suburban, or rural areas, this is a vital topic, 
and I am pleased that the subcommittee is considering the issue 
today. I welcome all of our distinguished witnesses here today, 
including Gary Carnes from my home State of Florida.
    I am interested in hearing about the challenges facing 
Federal, State, and local governments, and the medical 
community in addressing medical surge capacity and capabilities 
during a natural disaster, terrorist attack, or other mass 
casualty event, and in discussing those challenges, I hope our 
witnesses will provide us with recommendations for what more 
Congress can do to assist in these efforts. I would also like 
to hear about the lessons we learned as a result of the H1N1 
outbreak last year. Many experts say we dodged the bullet with 
this pandemic and that it could have been far worse and 
exceeded our medical capacity to respond successfully.
    How did this test current capabilities and what changes 
will you make to adapt to issues that arose? In light of H1N1's 
impact on children, I am particularly interested in learning 
about the challenges faced by the medical community in caring 
for children and other special needs populations during this 
pandemic and in other medical emergencies. Influenza is not the 
only medical crisis that could push the hospitals and other 
medical facilities to the edge of their capacity. A 
radiological or nuclear bomb, a chemical explosion, or a 
biological attack could cause emergency rooms to be flooded 
with patients in ways in which hospitals are ill-prepared to 
respond.
    What would your hospital do with radioactive patients, with 
patients that might be contaminated with anthrax spores? I look 
forward to hearing from our local witnesses on their ability to 
surge to meet the special needs of a bio-hazard event. Medical 
surge is a problem faced by our local communities and health 
care professionals, but because the ability to care for mass 
casualties is a homeland and health security matter local 
efforts must be supported by the Federal Government. That is 
why I have introduced H.R. 4492, which reauthorizes the 
Metropolitan Medical Response System Program and allows funding 
to be used to strengthen medical surge capacity, develop plans, 
and conduct training and exercises among other vital 
activities.
    In addition, H.R. 4492 authorizes funding to ensure this 
program reaches its full potential. I look forward to working 
with our witnesses on additional ways to support medical 
preparedness and surge capacity efforts. Thank you, Mr. 
Chairman. I yield back the balance of my time.
    Mr. Carney. Today's hearing will be divided into two 
panels. The first panel is comprised of Government witnesses, 
and the second will be comprised of representatives from 
hospital facilities. I welcome each of our witnesses to the 
hearing and to Pennsylvania. Our first witness is Dr. B. Tilman 
Jolly. Dr. Jolly is the Associate Chief Medical Officer for 
Medical Readiness in the Department of Homeland Security's 
Office of Health Affairs. Dr. Jolly began his service with DHS 
in November 2006. The Office of Health Affairs oversees efforts 
to coordinate medical first responders, ensures interagency 
alignment of health and medical preparedness grants, develop 
policies and programs to enhance all hazardous planning, 
promote integration of State and local response capabilities, 
and prepare for and respond to catastrophic events.
    Dr. Jolly has practiced emergency medicine in the 
Washington, DC area for 17 years. He remains Associate Clinic 
Professor of Emergency Medicine at the George Washington 
Hospital. In 1992, he completed training at the Georgetown-
George Washington combined residency in emergency medicine and 
is a Board-certified emergency physician. He has been a staff 
physician at numerous hospitals and continues to practice at 
Enola Fairfax Hospital, a regional trauma center, for northern 
Virginia. A native of North Carolina, Dr. Jolly received his 
undergraduate degree from the University of North Carolina as a 
Morehead Scholar and has a medical degree from Bowman Gray 
College School of Medicine at Wake Forest University. He 
resides in northern Virginia with his wife and four children.
    Our second witness is Dr. Gregg A. Pane. Dr. Pane is 
currently the Director of National Health Care Preparedness 
Programs for the U.S. Department of Health and Human Services. 
The program provides $500 million on grant funding to States 
and partnerships to improve National hospital and health system 
preparedness. From 2004 to 2007, Dr. Pane was the director of 
the District of Columbia Health Department or DOH. In that 
position, he headed a $2 billion 1,300 staff agency responsible 
for Medicaid public health programs, health facility and 
professional board licensing and certification, State health 
planning, and epidemiology, environmental health, and public 
health preparedness.
    While at DOH, Dr. Pane led the emergency response for 
anthrax, mercury spills, pandemic flu, the flu vaccine crisis, 
Katrina evacuees, and the 2005 Presidential inauguration. Dr. 
Pane was born in Flint, Michigan, and received his 
undergraduate degree of the University of Michigan at Flint. 
Dr. Pane holds a medical degree from the University of Michigan 
and a Master's degree in public health services administration 
from the University of San Francisco. He has made numerous 
appearances on local and National media, including CNN, NPR, 
Fox, CBS, BBC, ABC, and Japanese TV.
    Our third witness is Ms. Shannon Fitzgerald. She is the 
Director of the Office of Public Health Preparedness which 
supports the Pennsylvania Department of Health's efforts to 
prepare for and protect against, respond to, and recover from 
all acts of bioterrorism and other public health emergencies. 
As OPHP director, Ms. Fitzgerald's responsibilities include 
developing and administering Pennsylvania's public health 
preparedness, operations, and bio-terrorism response capability 
and formulating policy and providing policy direction at the 
local, regional, and State-wide level.
    Prior to coming to the Pennsylvania Department of Health, 
Ms. Fitzgerald served as the Public Health Preparedness program 
manager for the Philadelphia Department of Public Health. Ms. 
Fitzgerald also was previously employed as the emergency 
preparedness planner for the southeastern Pennsylvania chapter 
of the American Red Cross. Ms. Fitzgerald received a Master's 
of city planning and a Master's of government administration 
from the University of Pennsylvania in Philadelphia, and a 
Bachelor's of Sociology from the University of Dayton in 
Dayton, Ohio.
    Our fourth witness is Ms. Cynthia Bascetta. Ms. Bascetta 
serves as Director of Health Care Issues for the Government 
Accountability office or GAO. She is responsible for leading 
reviews of programs designed to protect and enhance public 
health. Ms. Bascetta is currently leading GAO's public health 
work with a focus on quality of care and disaster preparedness 
and response. She directs work on diverse issues such as 
prevention of health care association, associated infections, 
delivery of mental health services, and access to community 
health centers.
    She has also led reviews of the Federal response to 
Hurricane Katrina and the attack on the World Trade Center. 
Before that, she directed GAO's reviews of the effectiveness 
and the efficiency of VA's health care system and disability 
compensation programs at the Department of Veterans Affairs and 
the Department of Defense. She joined the GAO in 1983 after 
conducting regulatory impact analysis of major occupational 
health rules at the U.S. Department of Labor. She has a 
Bachelor's degree in Government from Smith College and a 
Master's in applied economics from the University of Michigan, 
and a Master's in Public Health from the University of 
Michigan. The University of Michigan is highly represented here 
today.
    Without objection, the witnesses' full statements will be 
inserted in the record. I now ask each witness to summarize 
your statement for 5 minutes beginning with Dr. Jolly.

  STATEMENT OF B. TILMAN JOLLY, M.D., ASSOCIATE CHIEF MEDICAL 
 OFFICER FOR MEDICAL READINESS, DEPARTMENT OF HOMELAND SECURITY

    Dr. Jolly. Thank you, Chairman Carney, Ranking Member 
Bilirakis. I want to thank you for the opportunity to 
participate in this field hearing to discuss the important 
issues of medical readiness and medical surge. I will just 
summarize my statement over a few minutes because I know we 
have a lot of important questions to get to. On behalf of 
Secretary Napolitano, who is very interested in these issues 
also personally, I would like to take the opportunity to thank 
you and the subcommittee for your continued work alongside DHS 
to provider leadership in protecting and ensuring the safety 
and preparedness of the homeland. I would also like to thank 
our Federal, State, local, and other partners, and particularly 
the partners from DHHS, with whom we work every day on a 
continual basis. This is just sort of an extension of that up 
here in a different city, but this is a group that we work with 
daily on all these issues.
    Today I am going to address just some basics of medical 
readiness and medical surge and talk a bit about the Office of 
Health Affairs in the Department of Homeland Security and the 
other departments of the Department of Homeland Security that 
work on these issues. Medical surge is an element of our 
overall preparedness but one of many critical elements, and as 
anyone who has worked around hospitals and around health care 
facilities knows the interconnectedness of those facilities 
into broader community critical infrastructures is key, 
especially when a crisis happens. All of the infrastructures 
need to work together, emergency preparedness, transportation, 
water, and others to make the system work.
    Now what I will talk about are some of the specific local 
response issues. In fact, Dr. Pane and I both had long 
experience in health care systems and a system like Geisinger 
who was very gracious to us this morning to show us their new 
facility really operates on a surge model every day because 
things happen for specific hospitals and communities every day 
from a bus rolling over to a fire to a critical response, and 
hospitals are quite good at managing their resources locally 
and even reaching out through mutual aid agreements to their 
county and regional partners to effect a response, and this 
something they work on and practice and can teach us a lot 
about.
    But when a large-scale either natural disaster or terrorist 
event happens, those that you talked about, radiation-related, 
nuclear-related, biological, chemical, or others, it really 
requires a regional, National, and sometimes, as we see 
tragically today, international response to manage and to get 
the flow of goods, health care to the affected people and 
sometimes to get those people out of where they are into 
definitive care. In these situations, DHS is the overall 
response manager under the National Response Framework that has 
been tried and tested in many situations, and also under the 
framework of the Department of Health and Human Services to 
lead for what we call ESF-8, Emergency Support Function--8, 
which is public health and medical which is clearly a key among 
the 15 emergency support functions.
    DHS through the Secretary and through the FEMA 
administrator lead the overall management of that and work very 
closely with Secretary Sebelius and her staff to effect these 
responses. Now our office, the Office of Health Affairs, which 
is relatively new in the Federal Government, serves as the 
principal health and medical advisor to both the Administrator 
of FEMA and to Secretary Napolitano. On a very practical level 
that occurs almost daily for things like H1N1, for other 
threats, for emergency response to natural disasters and other 
like incidents.
    Through our Office of Medical Readiness, which resides 
within my purview, we work with other DHS components and with 
our Federal partners and with State and local partners to work 
on some of the integration issues which you have highlighted. 
We also on an operational basis moved to staff the National 
Response Coordination Center, the National Operations Center, 
the Secretary's Operation Center at HHS to improve that 
coordination flow when there is an operation required and move 
through that to effect communications. You talked a bit, Mr. 
Bilirakis, about trusted relationships, and Mr. Carney both, 
about how those trusted relationships are formed. We are also 
working in a specific way with some of the fusion centers 
around the country to try to in effect improve collaboration 
between public health and the largely law enforcement elements 
that brought up those fusion centers, and that is a work in 
progress but I think something that is a goal that the prior 
Secretary and the current Secretary both endorse and want to 
move forward on.
    Now there is, of course, a pandemic going on and we talk a 
lot about what we have learned from H1N1. Although after-action 
is really not the right term to apply to something that is 
still going on but the process of gathering data and 
information about how that response happened, what our 
assumptions were at the beginning of that incident and even 
before that incident, and how we have learned how to do that 
communication. We are working very closely with Dr. Pane's 
office to gather information now. I think we have learned a lot 
about how to educate the public, how to educate providers, and 
how to educate communities about how to handle unusual long-
lasting biological events, and we look forward to working with 
you on that. I will close now and just thank you for your time 
and look forward to working with you and yield to Dr. Pane.
    [The statement of Dr. Jolly follows:]
                 Prepared Statement of B. Tilman Jolly
                              introduction
    Good morning Chairman Carney, Ranking Member Bilirakis, and Members 
of the subcommittee. Thank you for the opportunity to participate in 
this field hearing to discuss medical readiness and medical surge 
issues. On behalf of Secretary Napolitano, I would like to take this 
opportunity to thank you and the subcommittee for your continued work 
alongside the Department of Homeland Security (DHS) to provide 
leadership in protecting and ensuring the security of our homeland. I 
would also like to thank our Federal, State, local, Tribal, 
territorial, and private sector partners, including the Department of 
Health and Human Services (HHS) and others with whom we work every day.
    Today I will address medical readiness and medical surge within the 
scope of overall emergency preparedness and response capabilities. In 
particular, I will discuss the roles and responsibilities of the DHS 
Office of Health Affairs (OHA), and highlight key areas of coordination 
between DHS and HHS.
    HHS is the lead Federal agency for public health and medical 
preparedness and response issues and consequently coordinates and 
provides the health care and medical response in a major disaster or 
other catastrophic incident. DHS supports HHS in this mission.
     coordination with the department of health and human services
    The authorities for mass casualty events are enumerated in several 
places, including the National Response Framework (NRF) Emergency 
Support Function--8: Public Health and Medical Services, as well as in 
statutory authorities. Per the NRF, HHS is the lead Federal agency in 
preparing, deploying, and providing health and medical care to the 
public in the event of a disaster or other emergency.
    OHA and FEMA both work closely with the HHS Office of the Assistant 
Secretary for Preparedness and Response and the Centers for Disease 
Control and Prevention on a daily basis to bolster our ability to 
effectively prepare for and respond to a major emergency.
            department of homeland security responsibilities
    The Department of Homeland Security's mission is to secure the 
country against the many threats we face; should a catastrophic 
incident occur, DHS leads overall incident management activities.
    Medical surge capacity is a critical element of local, State, and 
National resiliency. Local medical providers deal with localized surge 
needs on a regular basis. Mutual aid agreements, communications 
protocols, and coordinated plans, all utilized by skilled professionals 
enable communities to deal with localized emergencies. The Federal 
Government will continue to support local capabilities as we assist in 
the coordination of broader regional capabilities.
    The focus of our planning at the Federal level is on crises that 
overwhelm local and State resources. When a large-scale natural 
disaster or terrorist incident occurs, the ability to provide urgent 
and life-saving medical care, through coordinated resources from the 
local, State, and Federal levels, directly affects the ability to save 
lives.
    Whether the event is the detonation of an improvised nuclear device 
or an influenza pandemic, the capacity to handle a large number of 
casualties will be the fundamental standard by which we measure success 
in our overall response.
    In a large multi-casualty event, many emergency departments and 
hospitals would be overwhelmed with individuals suffering from 
illnesses and injuries ranging from relatively minor to life-
threatening. In this situation, HHS would serve as the lead agency for 
coordinating health response activities. DHS would be responsible for 
support to facilitate effective medical response within the context of 
all the other demands of the event, including law enforcement, 
environmental, intelligence-gathering, public safety, communications, 
and search and rescue.
office of health affairs medical readiness and medical surge activities
    Within DHS, OHA serves as the primary advisor to the Secretary and 
the Administrator of the Federal Emergency Management Agency (FEMA) on 
medical and public health issues. OHA leads workforce health protection 
and medical oversight activities, leads and coordinates the 
Department's biological and chemical defense activities, and provides 
medical and scientific expertise to support DHS' preparedness and 
response efforts.
    OHA, through its Office of Medical Readiness and in collaboration 
with other DHS components and Federal departments and agencies, is 
working on a number of initiatives to improve our Nation's medical 
readiness. OHA plays an important supportive role in medical and health 
disaster planning, overseeing the health aspects of contingency 
planning for all chemical, biological, radiological, and nuclear 
hazards. OHA supports incident response operations by providing 
expertise and advice to the Secretary and FEMA Administrator and staff 
to the DHS National Operations Center and HHS Secretary's Operations 
Center, and assisting FEMA in evaluating State and local medical 
resource needs and requests during a disaster. OHA also provides 
medical subject matter expertise to FEMA's Homeland Security Grant 
Program, including the Metropolitan Medical Response System. OHA works 
to ensure that grant recipients across the country build medical 
response and medical surge capabilities by providing guidance and 
information to grant recipients and medical first responders. OHA is 
also facilitating medical and public health communities' participation 
in fusion centers. This coordination is beneficial because the health 
community can translate and share valuable health information, trends, 
and issues to inform actionable intelligence.
                        state and local response
    State and local responders play an essential role in the immediate 
aftermath of a catastrophic event. When a disaster strikes, it is the 
local first responders who arrive on the scene to provide initial 
assessment of the extent of the incident, the numbers of casualties, 
property damage, and resources needed to transport victims. Medical 
issues are addressed by local EMS, health care facilities, and public 
health agencies.
    Depending on the magnitude of the event, the response activities 
(including personnel, equipment, and supplies) will expand from local 
health resources to surrounding regions, State resources, adjoining 
State resources, and Federal resources. DHS is committed to ensuring 
that the Federal response, whether it is a medical, environmental, or 
law enforcement response, is well-coordinated with State and local 
officials to ensure a seamless and integrated response. The role of the 
Federal Government is to supplement State and local efforts and to 
provide assistance when it is needed.
    OHA and FEMA work closely with HHS, States, and local authorities 
to develop inter-State and multi-State agreements to provide supplies, 
hospital beds, and medical professionals during a catastrophic event. 
These partnerships are important to ensuring medical surge capacity.
                               conclusion
    Mr. Chairman, thank you for having this hearing today. Medical 
surge capacity is a significant part of any effective National 
emergency preparedness and response capability. I would be happy to 
answer any questions.

    Mr. Carney. Thank you for your testimony. Dr. Pane for 5 
minutes, please.

  STATEMENT OF GREGG A. PANE, M.D., DIRECTOR, NATIONAL HEALTH 
    CARE PREPAREDNESS PROGRAMS, OFFICE OF PREPAREDNESS AND 
  EMERGENCY OPERATIONS, OFFICE OF THE ASSISTANT SECRETARY FOR 
   PREPAREDNESS AND RESPONSE, DEPARTMENT OF HEALTH AND HUMAN 
                            SERVICES

    Dr. Pane. Yes. Thank you, Chairman Carney, Ranking Member 
Bilirakis. It is a pleasure to be here with my colleague, Til 
Jolly, and others. Dr. Lurry and Dr. Yeski send their regards. 
We are in the middle of the Haiti response and getting ready 
for the State of the Union this week, a lot going on. I did 
want to before I start summarizing my testimony thank you for 
arranging the tour of Geisinger Medical Center today. I think 
it was extraordinarily impressive state-of-the-art facility. It 
is wonderful seeing innovative going on locally, which is what 
we are hoping to achieve.
    Again, I am Gregg Pane. I am Director of the National 
Health Care Preparedness Program of HHS, which is the Hospital 
Preparedness Program and the Health Volunteer Program called 
ESAR-VHP. Again, it is a pleasure to be here. Briefly, as Dr. 
Jolly alluded to, our HHS Secretary, she is the lead Federal 
official for public health and medical response. We work very 
closely with DHS under the National Response Plan and support 
them in their lead role. This is all, of course, under the 
National Response Framework with HHS. ASPR, Assistant Secretary 
for Preparedness and Response is the entity which coordinates 
Federal public health and medical assistance to State, local, 
territorial, and Tribal jurisdictions during an emergency.
    Under the framework, HHS and DHS work very closely 
together, as Dr. Jolly alluded to. We have regular contact and 
meetings with the Office of Health Affairs, and certainly in 
times of response DHS and HHS work closely in each other's 
command centers and speak really daily and we work in each 
other's operations centers locally at the site of an incident 
as well. Of course, we work closely with FEMA and their 
officials. HHS has awarded over $300 million in funding to the 
State of Pennsylvania and over $477 million to the State of 
Florida through our combined HHS grant programs. One is the CDC 
Public Health Emergency Preparedness Program, known as the PHEP 
program, and the other is ASPR Hospital Preparedness Program 
known as HPP.
    I think PHEP has greatly increased the preparedness 
capabilities for public health departments across the country 
and includes targeted funding to support medical surge and the 
public health workforce. The Hospital Preparedness Program, 
HPP, is dedicated to enhancing medical surge capacity through 
cooperative agreements to States based on population. Funding 
is dedicated primarily for hospital emergency facilities, their 
communications needs, exercises, fatality management, and a 
host of other priorities.
    I did want to highlight while I was here the Healthcare 
Facilities Partnership of South Central Pennsylvania, which was 
one of the HPP demonstration pilots we were able to launch a 
couple of years ago. It was designed to improve surge capacity 
in the south central Pennsylvania region. It has provided 
simulation training to over 1,000 personnel within the 17 
institutions in the areas of pan flu, blast/mass casualty and 
hospital evacuation. I think it has helped promote mutual 
collaboration and problem solving through Hershey Medical 
Center and the acute care hospitals in the region to exercise 
as another contact.
    HHS has developed a mechanism to maintain situational 
awareness for hospital status called the HAvBED system, which 
is the Hospital Available Beds in Emergencies and Disasters. 
HAvBEDs are our primary way of understanding what beds are 
available to States and HHS operations centers, and States and 
hospitals respond within 4 hours of a request for the bed 
status. In 2005 the Florida Agency for Health Care 
Administration established the Emergency Status System, which 
is fully integrated with HAvBED requirements. This is a web-
based system designed to track impact of emergencies on 
providers, including hospitals, into an effective response to 
disasters.
    As I alluded to, a second part of the Hospital Preparedness 
Program is the ESAR-VHP program, Emergency System for Advanced 
Registration of Volunteer Health Professionals, a very 
important part. This is a National program intended to help 
health professionals volunteer in public health emergencies and 
disasters and to ensure the availability of volunteers for 
quick exchange between jurisdictions. HHS works very closely 
with States and communicates with them through various means. 
Our regional emergency coordinators are in regular contact with 
their counterparts. HPP leadership have regular calls and 
contact through meetings and calls with our State leaders in 
Hospital Preparedness.
    In addition, ASPR has a frequency of communications with 
FEMA, DHS, and we work closely with States during calls through 
their EOC and other mechanisms. Again, I will stop there and 
just say that our work to enhance medical surge continues to 
move forward. We thank you very much for your support and 
leadership in these areas. The responsibility for medical surge 
capacity is certainly one that is shared at the local, State, 
and Federal levels and includes private, as well as public 
partners, and it certainly starts with the individuals at home. 
So again with your leadership and support, we have made 
substantial progress. We thank you, and I am happy to take any 
questions.
    [The statement of Dr. Pane follows:]
                  Prepared Statement of Gregg A. Pane
                            January 25, 2010
    Good morning Chairman Carney and distinguished Members of the 
subcommittee. I am Dr. Gregg A. Pane, the Director of National Health 
Care Preparedness Programs in the Office of Preparedness and Emergency 
Operations, within the Office of the Assistant Secretary for 
Preparedness and Response (ASPR), U.S. Department of Health and Human 
Services (HHS). It is a privilege to present to you the progress HHS 
has made in our Nation's public health preparedness, specifically our 
work with Federal, State, and local partners to enhance surge capacity 
within the medical community. I want to also commend this subcommittee 
for its leadership in holding today's hearing and share your sense of 
urgency on this important issue.
               pandemic and all-hazards preparedness act
    The Pandemic and All-Hazards Preparedness Act (the act) designates 
the HHS Secretary as the lead Federal official for public health and 
medical response to public health emergencies and incidents covered by 
the National Response Plan developed pursuant to section 502(6) of the 
Homeland Security Act of 2002, or any successor plan, and creates the 
Assistant Secretary for Preparedness and Response. Under the act, ASPR 
plays a pivotal role in coordinating emergency public health and 
medical response efforts across the various HHS agencies and among our 
Federal interagency partners.
    Public health preparedness involves a shared responsibility among 
our entire Department, our partners in the international community, the 
Federal interagency, State, local, Tribal, and territorial governments, 
the private sector, and, ultimately, individuals and families. In 
addition, we believe that medical surge capacity is part of an all-
hazards approach to preparedness. The gains we make in increased 
preparedness and response capability help us across the spectrum of 
public health emergencies and disasters.
         coordination with the department of homeland security
    HHS supports DHS in its role as the lead for the integrated Federal 
response under the National Response Framework (NRF). Within the NRF, 
HHS is responsible for coordinating the Emergency Support Function 
(ESF) No. 8--Public Health and Medical Services and ASPR has been 
designated by HHS as the office to coordinate the Federal public health 
and medical assistance to State, local, territorial, and Tribal 
jurisdictions during an emergency.
    ASPR works closely with the Department of Homeland Security's 
Office of Health Affairs (OHA) and the Federal Emergency Management 
Agency (FEMA). At the Headquarters level, ASPR and OHA have weekly 
telephone meetings to discuss issues and activities of mutual interest. 
During times of response, DHS and FEMA participate in the ESF No. 8 
teleconferences and they send liaison officers to the HHS Operations 
Center. HHS also sends liaison officers to the FEMA National Response 
Coordination Center and to the FEMA Regional Response Coordination 
Center in the affected area. At the Regional level, HHS has regional 
emergency coordinators who work closely with the FEMA Regional 
Administrators to coordinate Federal preparedness and response 
activities within the region. HHS and DHS continue to work on 
coordinating our grant assistance to States. We have an established 
working group which is coordinating the programmatic aspects of our 
respective grants programs. Within each of these important coordination 
mechanisms, Federal interagency partners also report their activities 
for group discussion and integration.
                    regional emergency coordinators
    HHS has worked diligently to partner with State, Tribal, 
territorial, and local officials to enhance their level of preparedness 
and to ensure they can see how HHS will respond to disasters. ASPR 
Regional Emergency Coordinators work with State/Tribal/territorial 
officials from the Departments of Health, Emergency Management, and 
Homeland Security to coordinate and enhance preparedness within the 
region. HHS Centers for Medicare & Medicaid Services (CMS) regional 
representatives also take an active role at the local level for 
hospital preparedness.
    To better serve Hospital Preparedness Program (HPP) recipients, 
ASPR began hiring regional coordinators for the HPP program last year 
and is scheduled to have a coordinator in each of the 10 HHS regions by 
the end of this fiscal year.
                 enhancing state and local preparedness
    The Department has awarded over $350 million in funding to the 
State of Pennsylvania through the ASPR Hospital Preparedness Program 
(HPP) and the Centers for Disease Control and Prevention (CDC) Public 
Health Emergency Preparedness Program (PHEP). Funding has been 
allocated for the upgrading of State and local medical surge capacity, 
including hospital emergency care, communication, exercises, and 
fatality management. A summary of fiscal year 2009 funding provided to 
Pennsylvania under these programs is below:

------------------------------------------------------------------------
                                                            Fiscal Year
                         Program                           2009 Funding
------------------------------------------------------------------------
Hospital Preparedness Program...........................     $14,103,046
ESAR-VHP in PA..........................................          60,000
Public Health Emergency Preparedness Program............      22,975,362
------------------------------------------------------------------------

                     hospital preparedness program
    The Hospital Preparedness Program (HPP) is a program dedicated to 
enhancing medical surge capacity (http://www.hhs.gov/aspr/opeo/hpp). 
Funding allocations are made through formula cooperative agreements to 
States based on population, and through competitive grants. HPP funding 
comes from annual appropriations, as well as certain supplemental 
appropriations, including $90 million from the Supplemental 
Appropriations Act 2009 (Pub. L. 111-32) and the Emergency Supplemental 
Appropriations Act to Address Hurricanes in the Gulf of Mexico and 
Pandemic Influenza, 2006 (Pub. L. 109-148). Generally, HPP funding is 
dedicated for hospital emergency facilities, communications, exercises, 
and fatality management. Priorities for Medical Surge that were 
evaluated as part of the State plan review are as follows:
   States have the ability to report available beds which is a 
        requirement in the 2006 Hospital Preparedness Program 
        Cooperative Agreement;
   Effective use of civilian volunteers as part of the 
        Emergency System for Advance Registration of Volunteer Health 
        Professionals (ESAR-VHP) and Medical Reserve Corps (MRC) 
        programs;
   Planning for Alternate Care Sites;
   Development of Health Care Coalitions that promote effective 
        sharing of resources in surge situations; and,
   Plans for providing the highest possible standards of care 
        in situations of scarce resources. ASPR partnered with the HHS 
        Agency for Healthcare Research and Quality (AHRQ) in the 
        development of a Community Planning Guide on Mass Medical Care 
        with Scarce Resources.
                       hpp demonstration project
    Beginning in September 2007, as part of the HPP program discussed 
above, an HPP demonstration project called the Healthcare Facilities 
Partnership of South Central Pennsylvania, was initiated in Hershey, 
Pennsylvania. The Partnership was designed to improve surge capacity 
and to enhance community and hospital preparedness for public health 
emergencies in defined geographic areas within the South Central 
Pennsylvania region and was successful in achieving the following 
goals:
    1. Enhanced situational awareness of capabilities and assets in the 
        South Central Region of Pennsylvania;
    2. Develop and pilot test advanced planning and exercising of plans 
        in the Region;
    3. Complete written Medical Mutual Aid Agreements between health 
        care facilities in the Region, with a special emphasis on 
        hospitals;
    4. Develop and strengthen Partnership relationships through joint 
        planning, frequent communication, simulation, and evaluation of 
        preparedness;
    5. Ensure National Incident Management System (NIMS) Compliance, 
        including for the 14 new NIMS activities, for all hospitals in 
        the Region;
    6. Develop and test a plan for effective utilization of ESAR VHP 
        volunteers.
    The Partnership provided exercise solutions through the development 
and facilitation of three high fidelity simulations. To date it has 
provided simulation training to over 1,000 personnel within the 17 
institutions in the subject areas of: Pandemic Influenza Epidemic, 
Blast/Mass Casualty, and Hospital Evacuation. It also promoted mutual 
collaboration and problem solving with the acute care hospitals through 
frequent exercises.
    Recognizing the importance for continued training and evaluation in 
the areas of preparedness, the Partnership will use a mobile training 
and evaluation vehicle, called ``Lion Reach'' to provide a multitude of 
training opportunities for the South Central Pennsylvania Region. The 
Lion Reach training vehicle will support the partnerships on-going 
efforts to sustain the gains already achieved.
                                esar-vhp
    The Emergency System for Advance Registration of Volunteer Health 
Professionals (ESAR-VHP) is a National program intended to help health 
professionals volunteer in public health emergencies and disasters and 
to ensure the availability of volunteers for quick exchange between 
jurisdictions. The ESAR-VHP program is working to establish a National 
network of systems, each maintained by a State or group of States, for 
the purpose of verifying the credentials, certifications, licenses, and 
hospital privileges of health care professionals.
    ESAR-VHP in the State of Pennsylvania is known as the State 
Emergency Registry of Volunteers in Pennsylvania, or SERVPA, which is 
fully operational. Pennsylvania meets the ESAR-VHP compliance 
requirements and works to continue adopting and implementing the 
Interim ESAR-VHP Technical and Policy Guidelines, Standards, and 
Definitions.
              public health emergency preparedness program
    From fiscal year 2002-fiscal year 2009, the Public Health Emergency 
Preparedness (PHEP) program has provided $245 million to the State of 
Pennsylvania. This amount includes targeted funding to support medical 
surge and the public health workforce. The PHEP may be found at 
www.bt.cdc.gov/cotper/coopagreement.
    Generally, this program has greatly increased the preparedness 
capabilities of public health departments:
   All States can receive and evaluate urgent disease reports 
        24/7, while in 1999 only 12 could do so.
   All States now conduct year-round influenza surveillance.
   The number of State and local public health laboratories 
        that can detect biological agents as members of CDC's 
        Laboratory Response Network (LRN) has increased to 110 in 2007, 
        from 83 in 2002. For chemical agents, the number increased to 
        47, from 0 in 2001. Rather than having to rely on confirmation 
        from laboratories at CDC, LRN laboratories can produce 
        conclusive results. This allows local authorities to respond 
        quickly to emergencies.
   All States have trained public health staff roles and 
        responsibilities during an emergency as outlined in the 
        Incident Command System, while in 1999 only 14 did so.
   All States routinely conduct exercises to test public health 
        departments' ability to respond to emergencies. Such exercises 
        were uncommon before PHEP funding.
    PHEP has helped to improve the preparedness capabilities of the 
State of Pennsylvania through the following initiatives:
Citizen Education and Preparedness Outreach Campaign (CEPOC)
    The Pennsylvania Department of Health (PA DOH), Office of Public 
Health Preparedness (OPHP) along with the Pennsylvania Emergency 
Management Agency (PEMA) and other State agencies worked together to 
implement a multi-year CEPOC. This CEPOC is designed to reach all 
Pennsylvanians and provide all-hazards public health education 
information. The focus of the PA DOH CEPOC is to mitigate mortality and 
morbidity and minimize public health infrastructural damages during a 
manmade or natural event.
    The Pennsylvania Emergency Management Agency (PEMA), with support 
from the Pennsylvania Department of Health (PA DOH) and other State 
agencies, created a centralized emergency planning resource repository 
that provides consistent preparedness messaging in the Commonwealth, 
called READYPA. READYPA provides direction and information to citizens 
and communities on the importance of being prepared by highlighting 
personal preparedness strategies. The theme of the campaign is: Be 
Informed, Be Prepared, and Be Involved. A phone line, 1-888-9-READYPA, 
was launched in January 2009.
Special Medical Needs Response Plan
    Pennsylvania drafted a Special Medical Needs Response Plan--a 
comprehensive, standardized special medical needs response plan with a 
county and regional approach that is completely integrated into 
Pennsylvania's emergency response program. It is designed to guide 
local response efforts, identify the population, their location, and 
their needs and resources for an effective and timely emergency 
response. Temple University has pilot tested the draft Special Medical 
Needs Evacuation and Response template and Special Populations Planning 
Guide for first responders. The guide is designed to be a tool for 
local responders in developing a localized plan specific to the 
communities they serve. With this tool, the local, regional, and State 
response agencies will have a framework to further assist in developing 
localized plans for their target communities with special needs, 
including providing adequate staffing during an emergency, and allowing 
sufficient time to train the responders
                             communication
    HHS employs a variety of mechanisms to ensure that communications 
with States remains operational at all times. Most of our 
communications are directed to the State Health Departments who then 
distribute that information to local organizations. Our Regional 
Emergency Coordinators are in regular communications with their State 
counterparts. Our HPP leadership conducts monthly calls with their 
grant recipients, usually the State HPP project officer, monthly. 
During responses within a State, ASPR increases the frequency of the 
communications with the States. We have liaison officers in the State 
EOC. After responses, we conduct after-action sessions to assess our 
response and we invite State/local representatives to provide input.
    With regard to communications with clinicians, HHS conducts 
teleconferences with providers who can then speak with subject matter 
experts. For example, during the on-going H1N1 pandemic, CDC conducted 
calls with providers to answer questions regarding the disease and its 
treatment. ASPR held teleconferences with critical care clinicians to 
discuss the care of patients who required intensive care. HHS also 
conducted calls with CMS to inform hospitals about their options 
regarding alternate care sites and other capacity expanding mechanisms.
    Other mechanisms to communicate with our State, local, Tribal, and 
territorial partners incorporate electronic means. CDC has both the 
Health Alert Network, which sends out electronic notices of health-
related issues of interest and the Epi-X program, which notifies State 
epidemiologists of disease outbreaks of interest and provides an 
electronic bulletin board for them to hold discussions.
    Both CDC and ASPR have websites which contain updated information 
on preparedness and response. Individual providers, as well as the 
general population have access to critical information relating to 
preparedness and response.
HAvBED
    HHS also has developed a mechanism to maintain situational 
awareness of hospital status. The ``Hospital Available Beds in 
Emergencies and Disasters'' (HAvBED) was developed by HPP in 
conjunction with the Agency for Healthcare Research and Quality as a 
means of collecting surge bed status in the time of a disaster. Use of 
this system (or compatible systems) is required by the Hospital 
Preparedness Program. Originally, this system required reports of 
available beds, including a count of available adult and pediatric 
general beds and ICU beds, to State and HHS emergency operations 
centers within 4 hours of request. During the H1N1 pandemic, the system 
was modified to collect information that might indicate health care 
system stress, as reflected by emergency department status and 
anticipated supply shortages. This information has been collected 
weekly. Within 48 hours of collection, information is analyzed and any 
concerns are passed back to State Health Departments through the RECs 
for action.
    The declaration by the President of H1N1 as a National emergency, 
coupled with the Secretary's Declaration of a Public Health Emergency, 
provides authority under section 1135 of the Social Security Act, to 
temporarily waive legal provisions or modify certain Medicare, 
Medicaid, CHIP, and HIPAA requirements if necessary, in order to 
provide hospitals with needed flexibility in emergency or pandemic 
situations to deal more effectively with patient surge needs rather 
than restrictive paperwork. This move has been welcomed by local 
hospitals, many of whom can now make requests of CMS for 1135 waivers 
in the event that increased patient loads due to H1N1 affect the 
availability of health care items and services. These requests are 
reviewed by CMS within 24 hours and can be granted retroactively to the 
beginning of the emergency period (that is, back to October 23, 2009) 
if necessary.
              homeland security presidential directive-21
    Homeland Security Presidential Directive (HSPD)-21, ``Public Health 
and Medical Preparedness,'' established a National Strategy for Public 
Health and Medical Preparedness. The Strategy aims to improve the 
Nation's ability to plan for, respond to, and recover from public 
health and medical emergencies and calls for the continued development 
of a robust infrastructure--including health care facilities, 
responders, and providers--which can be drawn upon in the event of an 
emergency. HSPD-21 also requires the ``establishment of a robust 
disaster health capability requires us to develop an operational 
concept for the medical response to catastrophic health events that is 
substantively distinct from and broader than that which guides day-to-
day operations.''
    To this end, HHS has also led the development of the National 
Health Security Strategy (NHSS), the first comprehensive strategy 
focusing specifically on protecting people's health in the case of an 
emergency (www.hhs.gov/aspr/opsp/nhss). Called for in PAHPA, the NHSS 
is designed to strengthen and sustain health and emergency response 
systems and build community resilience thereby enhancing medical surge 
capacity at all levels of community. The NHSS calls for active 
collaboration among individuals, families, and communities (including 
private sector and all governmental, non-governmental, and academic 
organizations) to implement strategies to prevent, protect against, 
respond to, and recover from any type of large-scale incident having 
health consequences.
    The National Health Security Strategy addresses additional steps 
that must be taken to ensure that adequate medical surge capacity, 
including a sufficiently sized and competent workforce available to 
respond to health incidents; a sustainable medical countermeasure 
enterprise sufficient to counter health incidents is fostered; and 
increased attention to building more resilient communities and 
integrating the public, including at-risk individuals, into National 
health security efforts. HHS is also leading the development of an NHSS 
Implementation Plan to identify the steps that are needed to enhance 
medical surge capacity.
Emergency Care Coordination Center
    The Emergency Care Coordination Center (ECCC) was established in 
response to the Department's identification of the pressing needs of 
the Nation's emergency medical system (www.hhs.gov/aspr/opeo/eccc). The 
ECCC takes a regional approach to assist and strengthen the U.S. 
Government's efforts to promote Federal, State, Tribal, local, and 
private sector collaboration and to support and enhance the Nation's 
system of emergency medical care delivery. It is a collaborative effort 
involving the DoD, DHS, Department of Transportation and Department of 
Veterans Affairs. Its vision is exceptional daily emergency care for 
all persons of the United States and its mission is to promote Federal, 
State, local, Tribal, and private sector collaboration to support and 
enhance the Nation's emergency medical care.
    The ECCC strengthens our Nation's ability to respond to mass 
casualty events. The ECCC assists the U.S. Government with policy 
implementation and guidance on daily emergency care issues and promote 
both clinical and systems-based research. Through these efforts, ASPR 
and its Federal partners will improve the effectiveness of pre-hospital 
and hospital based emergency care by leveraging research outcomes, 
private sector findings, and best practices. The ECCC promotes improved 
daily emergency care capabilities to improve the resiliency of our 
local community health care systems.
                               conclusion
    Our work to enhance medical surge continues to move forward. The 
responsibility for medical surge capacity is shared at the local, 
State, and Federal levels and includes private as well as public 
partners. HHS has provided funding and guidance to our Pennsylvania 
State partners and we have actively engaged in workshops and exercises 
with our State and local partners to advance preparations. With the 
leadership and support of Congress, we have made substantial progress. 
The threats to public health remain real, and we have much left to do 
to ensure that we meet our mission of a Nation prepared.

    Mr. Carney. Thank you, Dr. Pane. Ms. Fitzgerald for 5 
minutes, please.

STATEMENT OF SHANNON FITZGERALD, DIRECTOR, PENNSYLVANIA OFFICE 
   OF PUBLIC HEALTH PREPAREDNESS, PENNSYLVANIA DEPARTMENT OF 
                             HEALTH

    Ms. Fitzgerald. Okay. Thank you, and, good morning, 
Chairman Carney and Ranking Member Mr. Bilirakis. My name is 
Shannon Fitzgerald, and I am the Director of the Office of 
Health Preparedness with the Pennsylvania Department of Health 
as the department's lead on matters related to public health 
preparedness and response. Secretary Everette James has asked 
me to address the important issue of medical surge capacity and 
answer any questions you may have. Thank you very much for this 
opportunity. Medical surge capacity is a broad subject with 
many areas of focus, and today I am going to focus on four 
specific areas of medical surge capacity and how the 
Pennsylvania Department of Health has contributed to enhancing 
medical surge capacity across the State.
    The four areas are defined in a 2008 GAO report authored by 
Ms. Bascetta sitting next to me here, and they include 
increasing hospital capacity, including beds, workforce, 
equipment, and supplies; identifying and operating alternative 
care sites when hospital capacity is overwhelmed; registering 
and credentialing volunteer medical professionals; and planning 
for appropriate altered standards of care in order to save the 
most lives in a mass casualty event. The department works 
diligently with health care, Government, and non-profit 
partners to build and support medical surge capacities and 
capabilities throughout the State.
    The first area of medical surge capacity that I will 
discuss is increasing hospital capacity. Since 2002, the 
Pennsylvania Department of Health has received funding from the 
Department of Health and Human Services, their hospital 
preparedness program, and we have pushed significant funding 
directly out to hospitals in order to improve individual 
hospital capacity. In 2009-2010, we received over $14 million 
in funding and almost 60 percent was distributed directly to 
175 hospitals with emergency departments. Hospitals over the 
past several years have used this funding to improve their 
preparedness at the hospital level and need the hospital 
preparedness program capabilities, including personal 
protective equipment and decontamination and improving 
pharmaceutical caches, et cetera.
    In addition, we have used our funding to enhance our 
laboratory capacity and have purchased two bio-safety level 
three mobile laboratories which can be deployed anywhere within 
the Commonwealth within a matter of hours. Verifying the 
availability of hospital resources during an emergency is 
essential, and the way that we identify resources such as 
equipment and supplies, as well as hospital beds, is through a 
State-owned and operated database called FRED, or our Facility 
Resource Emergency Database. We use the system FRED to collect 
data and upload it into the Federal HAvBED system during the 
2009 H1N1 influenza response.
    Another example of how we have contributed to increasing 
medical surge capacities through a burn training program, and 
we have established both a burn training program, as well as 
purchased additional burn supplies in the northeastern part of 
the State, and there has been 24 burn carts that have been 
pushed out throughout the northeastern part of the State which 
really allows through the training and the burn cart allows 
patients to receive critical care within the first 24 hours 
prior to being able to be transported to a burn facility.
    The second area of medical surge capacity is alternate care 
sites, and we have purchased mobile medical assets, including 
portable hospitals and medical surge trailers, which can serve 
as alternate care sites wherever there is a need in the 
Commonwealth. Currently, we have eight portable hospital 
systems and 19 medical surge trailers that can be deployed on a 
moment's notice. The third area of medical surge capacity is 
volunteer medical professionals. Pennsylvania is meeting the 
Federal ESAR-VHP requirement to recruit and train medical 
professionals through out State Emergency Registry of 
Volunteers in Pennsylvania or SERVPA. Currently, we have over 
6,400 registered volunteers and 63 percent of those are medical 
professionals. We recently deployed several of them to assist 
us with our H1N1 at mass vaccination clinics.
    Another personal resource that we support through our 
Federal funding is the State Medical Response Team, and that is 
a team that has purchased equipment and supplies and they train 
personnel and they are ready to deploy. They are similar to the 
Federal DMAP program but it is a local resource. We also have a 
robust medical surge personnel resource through our Emergency 
Medical Services system. Over 54,000 EMS personnel assist with 
over 1.8 million patient transports per year. We used our 
Emergency Medical Services personnel to help supply surge 
resources once again during the 2009 H1N1 event. They assisted 
with mass vaccinations at our clinics.
    The final area of surge capacity is altered standards of 
care, and we are in the process of finalizing a nine volume 
medical surge capacity guidance document that is intended to 
provide a coordinated State-wide health and medical surge 
strategy and direction to the wide audience of health care 
practitioners, health care facility or systems administrators, 
community-based public health and public safety partners and 
responders. We plan on rolling out this guidance document later 
this spring, and one of the volumes addresses the very 
important piece of modified delivery of care with health care 
and scarce resources. So we look forward to rolling out this 
guidance document and then working with our partners throughout 
the State to train on it and to hold discussions on how to 
implement medical surge and altered standards of care State-
wide. Thank you very much for this opportunity to present 
today. I am happy to take your questions.
    [The statement of Ms. Fitzgerald follows:]
                Prepared Statement of Shannon Fitzgerald
                            January 25, 2010
    Good morning Chairman Carney and Members of the House Committee on 
Homeland Security's Subcommittee on Management, Investigations, and 
Oversight. My name is Shannon Fitzgerald and I am the Director of the 
Office of Public Health Preparedness, with the Pennsylvania Department 
of Health (department). As the department's lead on matters related to 
public health preparedness and response, Secretary Everette James has 
asked me to address the important issue of medical surge capacity and 
answer any questions that you may have. Thank you for this opportunity.
    Medical surge capacity is a broad subject with many areas of focus. 
I am going to focus on four specific areas of medical surge capacity 
and how the Pennsylvania Department of Health has contributed to 
enhancing medical surge capacity across the State. The four areas are 
defined in the June 2008 United States Government Accountability Office 
report to Congressional Requests titled, ``Emergency Preparedness, 
States are planning for medical surge, but could benefit from shared 
guidance for allocating scarce medical resources.'' The four areas 
include: ``(1) increasing hospital capacity, including beds, workforce, 
equipment, and supplies; (2) identifying and operating alternate care 
sites when hospital capacity is overwhelmed; (3) registering and 
credentialing volunteer medical professionals; and (4) planning for 
appropriate altered standards of care in order to save the most lives 
in a mass casualty event.''\1\
---------------------------------------------------------------------------
    \1\ GAO-08-668 ``Emergency Preparedness: States are planning for 
medial surge, but could benefit from shared guidance for allocating 
scarce medical resources,'' June 2008.
---------------------------------------------------------------------------
    The department works diligently with health care, Government, and 
non-profit partners to build and support medical surge capacities and 
capabilities throughout the State.
    The first area of medical surge capacity that I will discuss is 
increasing hospital capacity. Since 2002 Pennsylvania has received the 
Department of Health and Human Services, Office of the Assistance 
Secretary for Preparedness and Response, Hospital Preparedness Program 
(HPP) funding. This funding must be utilized to exercise and improve 
preparedness plans for all-hazards and enhance the capacities and 
capabilities of health care systems. In the 2009-2010 HPP grant year, 
the department received over $14 million in HPP funding. Almost 60% of 
the funding was distributed to 175 hospitals with emergency departments 
for preparedness activities. The hospitals are required to utilize this 
funding to meet the HPP overarching requirements that include, National 
Incident Management Systems, Needs of At-Risk Populations, Education 
and Preparedness Training and Exercises, Evaluation and Corrective 
Actions; Level One Sub-Capabilities including, Interoperable 
Communication Systems, Tracking of Bed Availability, Emergency System 
for Advance Registration of Volunteer Health Professionals also called 
ESAR-VHP, Fatality Management, Medical Evacuation/Shelter in Place, 
Partnership/Coalition Development; and Level Two-Sub-Capabilities 
including, Alternate Care Sites, Mobile Medical Assets, Pharmaceutical 
Caches, Personal Protective Equipment, Decontamination, Medical Reserve 
Corps and Critical Infrastructure Protection. Hospitals have utilized 
the HPP funding since 2002 to meet these objectives and to purchase 
medical surge items including, but not limited to the following:
   supplies and equipment to support medical surge activities 
        (i.e., beds, cots, ventilators, linens, evacuation sleds and 
        chairs, trauma kits, burn supplies, utility carts, wheel 
        chairs, automatic external defibrillators, and suction units);
   negative pressure isolation supplies and equipment;
   pharmaceutical caches of medications to provide prophylaxis 
        to staff members and their families during disaster situations;
   communication and information technology equipment (i.e., 
        radios, telephones, computer equipment, televisions, electronic 
        notification boards);
   facility support supplies and equipment (i.e. emergency 
        generators, incident command needs, mobile medical assets, 
        portable lighting, security items, trailers);
   personal protective equipment for staff;
   decontamination supplies and equipment;
   education and training expenses;
   exercise expenses;
   laboratory surge equipment; and
   conduct emergency preparedness and response planning.
    The department has enhanced our laboratory capacity with the 
purchase of two biosafety level 3 (BSL-3) mobile laboratories which can 
be deployed to any site in the Commonwealth within hours. The mobile 
laboratories are equipped with robotic prep-stations and real-time 
polymerase chain reaction (PCR) instrumentation for rapid pathogen 
identification. All of the equipment can be powered via landline or on-
board diesel generators. The mobile laboratories can conduct swine and 
avian influenza testing and test for select agents, toxins, and 
chemical terrorism agents.
    Verifying the availability of hospital resources during an 
emergency is essential. The department uses the State-owned and 
operated Facility Resource Emergency Database (FRED) to notify 
hospitals of potential events and to collect real-time data from 
hospitals, using a web-based application. The system can collect any 
data required for the event, including the availability of various 
types of hospital beds, including adult intensive care beds, medical/
surgical beds, burn beds, pediatric beds, etc. The system can also 
collect data on the number of ventilators and pharmaceuticals 
available. The department tests this system on a monthly basis and 
utilizes this system to collect the bed data (Hospital Available Beds 
for Emergencies and Disasters/HAvBED) required by the U.S. Department 
of Health and Human Services during the 2009 H1N1 influenza response.
    Another example of how the department has contributed to increasing 
medical surge capability is through a burn training program. The 
department has provided funding to support burn training for over 1,200 
medical providers throughout the Commonwealth. The 8-hour course is 
designed to ensure pre-hospital and hospital personnel are ready in the 
event of accidents or disasters involving burn injury. The course 
provides guidelines in the assessment and management of the burn 
patient during the first 24 hours post-injury until the patient can be 
transported to one of the limited number of burns beds in the 
Commonwealth or country. The Department has also provided funding for 
the creation of a burn surge program in the Northeast region of 
Pennsylvania. This program provides a higher level of burn care at 24 
regional hospitals and three mobile surge facilities in the Northeast 
region. The grant funded the creation of 27 burn carts for use at these 
hospitals and facilities. Each cart contains supplies and information 
to care for up to three moderately burned patients for 3 days. Training 
on the use of the carts for burn care was provided by the Lehigh Valley 
Health Network's Regional Burn Center to each hospital receiving a 
cart.
    The second area of medical surge capacity is alternate care sites. 
The Pennsylvania Department of Health has purchased mobile medical 
assets, including portable hospitals and medical surge trailers, which 
can serve as alternate care sites wherever there is a need in the 
Commonwealth.
    The Department has purchased eight portable hospital systems to 
increase the medical surge capacity in the Commonwealth. Each of these 
systems comes in two 28-foot trailers and contains all of the supplies 
and equipment needed to set up 50 hospital beds in a tent capable of 
providing a negative pressure environment. Each system has the 
materials necessary to care for up to 350 patients (or one patient per 
bed for 1 week). The portable hospitals increase the State-wide bed 
capacity by 400 beds and can be set up anywhere in the Commonwealth, 
thus increasing the number of available alternate care sites and 
allowing flexibility for the alternate care sites to be placed where 
most needed.
    The eight systems are stored in geographic locations throughout the 
State and can been entirely deployed within 90 minutes of arrival on 
the scene utilizing a crew of not more than six individuals. Each 
system includes the following medical surge equipment and supplies:
   supplies for receiving and classification (i.e., office 
        supplies, tables, chairs, walkie talkies, and megaphones);
   medical and patient care supplies;
   mortuary supplies;
   diagnostic supplies;
   housekeeping equipment and miscellaneous supplies;
   transportation system (one climate controlled trailer for 
        medical supplies and equipment and one trailer for support 
        materials); and
   support equipment (i.e., hospital tents, heater, negative 
        pressure capability, generators, waste systems, water systems, 
        and oxygen systems).
    The Pennsylvania Department of Health has also purchased nineteen 
medical surge trailers. Each of these trailers contain the supplies and 
equipment needed to set up 50 medical cots in a fixed facility. The 
medical equipment and supplies are assembled, stored in trailers, and 
pre-deployed to geographic locations throughout the Commonwealth. This 
resource utilizes a standard-size basketball court, as well as the 
perimeter of the court to place additional supplies or equipment. Each 
trailer will include the following medical surge equipment and 
supplies:
   supplies for receiving and classification (i.e., office 
        supplies, table, chairs);
   medical and patient care supplies; and
   transportation system (trailer).
    In addition to the mobile medical assets mentioned in this 
testimony, most hospitals have identified alternate care sites for 
short-term and long-term emergencies. Many hospital designated sites 
are located within the hospital campus or hospital-owned facilities off 
campus.
    To support medical surge operations within a hospital setting and 
at alternate care sites, the department has tested and is in the 
process of implementing a patient tracking system. The Commonwealth-
wide patient tracking system relies on bar-coded bands that will be 
placed on patients at a mass casualty scene. The bands are read by a 
scanner and important limited patient information will be loaded into a 
web-based application viewable by emergency response partners.
    The third area of medical surge capacity is volunteer medical 
professionals. The Pennsylvania Department of Health is meeting the 
Federal Emergency System for Advance Registration of Volunteer Health 
Professionals (ESAR-VHP) requirement through its State Emergency 
Registry of Volunteers in Pennsylvania (SERVPA) program. Pennsylvania 
has established an on-line registry for volunteers interested in 
responding to or assisting with a disaster or other emergency. The 
registry collects basic information from volunteers in advance of an 
emergency response situation. The registry verifies health care 
professional licenses with an automated link with the Department of 
State's licensure registry. SERVPA currently has 6,400 registered 
volunteers. Over 63% of the volunteers registered are health care 
personnel. In addition, Pennsylvania has 14 Medical Reserve Corps (MRC) 
teams with almost 3,000 volunteers.
    Another personnel resource to support medical surge needs are the 
three State Medical Response Teams (SMRTs) which are supported by the 
department. The SMRTs have purchased supplies and equipment and have 
trained personnel that are ready to deploy to a mass casualty or other 
emergency within a couple of hours to assist with patient triage and 
patient care. The SMRT from southeastern Pennsylvania deployed to the 
G-20 event in Pittsburgh in 2009. The combination of resources provided 
by the SMRT and an EMS Strike Team could have provided patient support 
for up to 350 patients per hour, including 24 burn patients, without 
tapping any of the local medical and hospital resources.
    Pennsylvania has a robust medical surge personnel resource within 
the emergency medical services (EMS) system. Over 54,000 EMS personnel 
assist over 1.8 million patients per year. The EMS system is organized 
into 16 Regional EMS Councils, 1,014 ambulance services, 517 quick 
response services and 63 air ambulances. The Department supports 150 
EMS Strike Teams made up of six EMS personnel each. These Strike Teams 
can be taken out of service and deployed without impacting local 
service delivery. Several EMS Strike Teams were deployed to Louisiana 
to support the efforts to respond to Hurricanes Katrina (2005) and 
Gustov (2008). EMS personnel have been trained on how to stand up and 
operate the portable hospitals and medical surge trailers and are the 
first line of personnel to be deployed with these systems.
    The department deployed many of these volunteer health professional 
resources to assist with the H1N1 public health vaccination clinics 
during the 2009 H1N1 influenza pandemic.
    The combination of these volunteer and professional groups, and 
other strategies employed by hospitals, including having staff work 12-
hour shifts, provide an extensive network of trained personnel to 
support a medical surge event.
    The final area of medical surge capacity is altered standards of 
care. The Pennsylvania Department of Health is in the process of 
finalizing a nine-volume (chapter) medical surge capacity guidance 
document intended to provide a coordinated, State-wide health and 
medical surge strategy guidance and direction to a wide audience, 
including health care practitioners, health care facility or system 
administrators, community-based public health and public safety 
planners and responders, volunteers, as well as local, regional, and 
State agencies. All nine volumes have been drafted and vetted through a 
multidisciplinary working group consisting of representatives from 
public health, emergency management, and hospital. The following 
subject areas are covered in the nine volumes:
   Volume I: System of Systems Approach: A comprehensive 
        overview;
   Volume II: Management System: The seamless integration of 
        multiple levels of medical direction, control, communications, 
        and coordination;
   Volunteer III: Alternate Care Sites: The use of a community-
        based triage system to maximize load-sharing and reduce surge 
        pressures;
   Volume IV: Modified Delivery of Healthcare with Scarce 
        Resources: Providing the best possible medical care to the 
        largest number possible;
   Volume V: Transportation System: Building depth and 
        redundancy for Emergency Medical Services (EMS), mortuary 
        affairs, and vendor-managed materiel movement throughout the 
        system and among patient care facilities;
   Volume VI: Resource Management System: Measures to ensure 
        protracted and sustained operations of health care facilities 
        and alternate care sites;
   Volume VII: Mass Fatality Management System: Leveraging 
        community mortuary affairs assets for the dignified and 
        environmentally safe handling and disposition of remains;
   Volume VIII: Community Outreach and Education System: 
        Coordinating a mutually supportive public information network 
        and campaign to achieve desired results; and
   Volume IX: Behavioral Health Support System: Providing 
        comfort and psychological care to responders, patients, and 
        families.
    Volume IV addresses the modified delivery of health care with 
scarce resources. It is intended to assist health care organizations in 
preparing for emergency situations where resources are inadequate to 
meet the necessary health care needs in the usual manner, compelling a 
change in health care delivery strategy. The objectives for modified 
health care delivery include the following:
   maintain a physically and medically safe environment for 
        staff, current patients, and visitors, and protect the 
        functional integrity of the health care organization;
   achieve and maintain optimal medical surge capacity and 
        capability with available resources;
   modify health care delivery, through managed change, to 
        maintain a safe environment and achieve the best possible 
        medical outcomes; and,
   return to normal operations as rapidly as possible and 
        return response resources to ready status.
    In addition to the medical surge guidance document, the 
department's Emergency Operations Plan describes Pennsylvania's plan 
for facilitating the organization, mobilization, and operation of 
health resources in response to natural or man-made incidents, 
including a medical surge capacity annex describing the operations plan 
for the portable hospital systems and medical surge trailers. The 
department works closely with heath care partners to develop, 
implement, and support emergency preparedness trainings and exercises 
that demonstrate medical surge capacity.
    Building and sustaining medical surge capacity is a multi-
jurisdictional effort requiring leadership and coordination. We will 
continue to work with our partners at the Federal, State, and local 
level to collaborate on medical surge capacity preparedness activities.
    On behalf of Secretary James, thank you for inviting the Department 
of Health to present this testimony. I am happy to answer your 
questions.

    Mr. Carney. Thank you, Ms. Fitzgerald. Ms. Bascetta, 5 
minutes, please.

   STATEMENT OF CYNTHIA A. BASCETTA, DIRECTOR, HEALTH CARE, 
                GOVERNMENT ACCOUNTABILITY OFFICE

    Ms. Bascetta. Good morning, Mr. Chairman, and Mr. 
Bilirakis. I am very pleased to be here today to discuss GAO's 
work on emergency preparedness, which we put on our list of 
urgent issues last year. As you know, the use of anthrax is a 
deadly weapon in the wake of the attack on the World Trade 
Center, Hurricane Katrina, pandemic flu, and potential for 
other disasters have raised concern about the ability of our 
Nation's health care systems to respond to natural and man-made 
mass casualty events. In such events, local or regional health 
care systems may be overwhelmed and unable to deliver services 
consistent with established standards of care. The ability of 
health care systems to surge was the subject of our June, 2008 
report and is the basis for my remarks today.
    We examined Federal support to the States to prepare for 
the four key components and again their increasing hospital 
capacity, operating alternate care sites, mobilizing volunteers 
and following altered standards of care, which I would now like 
to refer to as crisis standards of care. This is the new term 
for this. It was recently issued in an IOM report, Institute of 
Medicine, report. As you know, the Department of Homeland 
Security has the overall responsibility for managing National 
emergency preparedness and the Secretary of HHS is the lead for 
all Federal public health and medical responses to public 
health emergencies including that surge.
    States have the important responsibility for producing 
emergency preparedness plan in coordination with local and 
regional entities and both DHS and HHS are responsible for 
supporting those efforts. DOD and VA also assist State and 
local governments under certain conditions. To do our work, we 
focused on the hospital preparedness program and guidance from 
the Agency for Health Care Research and Quality. We analyzed 
cooperative agreements and mid-year progress reports for 20 
States, and we selected two States from each of HHS' ten 
regions, the ones with the most and the least hospital 
preparedness funding. We included Pennsylvania in our sample 
because it had the most funding for region three from HHS, and 
for this statement we also updated the status of HHS' response 
to our recommendation.
    We found that many States have made progress in preparing 
for medical surge but also reported significant challenges. All 
20 were developing bed reporting systems and most were 
coordinating with DOD and VA medical facilities to expand the 
number of hospital beds. At the same time, shortages of medical 
professionals raised some significant concerns about staffing 
those beds. Similarly, almost all of the States in our review 
were selecting facilities such as schools and churches for 
alternate care sites. Some, including Pennsylvania, also 
reported purchasing medical mobile facilities as you have just 
heard, and many States also reported that they developed plans 
for equipping and staffing their alternate care sites.
    However, they told us they needed guidance and assurance 
from CMS that they would be reimbursed for care provided at 
alternate care sites. CMS officials told us that they prefer to 
approve payment on a case-by-case basis after visiting sites 
because those facilities are not accredited. Regarding 
volunteers, most States reported that they had begun 
registering volunteers by profession in electronic registries 
although they had not all checked the volunteers' credentials. 
They were concerned that some medical volunteers might be 
reluctant to join a State registry if National deployment were 
to become a possibility. Other States also reported double 
counting of volunteers and more than one database, such as the 
Medical Reserve Corps and Disaster Medical Assistance Teams.
    In contrast to the progress made on the first three medical 
surge components only 7 of the 20 States at the time of our 
review had adopted or were drafting crisis standards of care. 
Many States reported the difficulty of addressing medical, 
legal, and ethical issues involved in allocating scarce 
resources such as pharmaceuticals and ventilators during a 
disaster. Some States reported using guidance from AHRQ but 
most reported that more Federal guidance would be helpful in 
deciding how to make these life and death decisions. We 
recommended that HHS serve as a clearinghouse for sharing 
crisis standards of care guidelines developed by individual 
States and medical experts.
    In commenting on our draft report, HHS was silent on our 
recommendation but we are pleased to report that HHS has 
recently taken steps to design such a clearinghouse and in 
addition they funded an IOM study that I referred to earlier. 
It was published in September, 2009 and provides guidance for 
establishing crisis standards of care. I would be happy to 
answer any questions you have.
    [The statement of Ms. Bascetta follows:]
               Prepared Statement of Cynthia A. Bascetta
    Mr. Chairman and Members of the subcommittee: I am pleased to be 
here today to discuss our work examining both the Federal assistance 
provided to States and the States' own efforts to help build the 
``surge capacity'' of the Nation's health care system to respond to 
mass casualty events. The September 11, 2001, terrorist attacks on the 
World Trade Center and the Pentagon, the anthrax incidents during the 
fall of 2001, and the H1N1 influenza pandemic of 2009 have raised 
public awareness and concern about the ability of the Nation's health 
care systems \1\ to respond to bioterrorism \2\ and other mass casualty 
events.\3\ In a mass casualty event the ability of local or regional 
health care systems to deliver services consistent with established 
standards of care \4\ could be compromised, at least in the short term, 
because the volume of patients would far exceed the available hospital 
beds, medical personnel, pharmaceuticals, equipment, and supplies. The 
Nation's health care system was tested by last year's H1N1 pandemic and 
may be challenged to respond to a large-scale public health emergency 
if there is a resurgence of the H1N1 influenza virus or some other 
strain of influenza in 2010.
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    \1\ By health care systems, we mean both public health and medical 
systems, including hospitals.
    \2\ A bioterrorism attack is the deliberate release of viruses, 
bacteria, or other germs (agents) used to cause illness or death in 
people, animals, or plants. These agents are typically found in nature, 
but it is possible that they could be changed to increase their ability 
to cause disease, to make them resistant to current medicines, or to 
increase their ability to be spread into the environment. Biological 
agents can be spread through the air, through water, or in food.
    \3\ A mass casualty event is a public health or medical emergency 
that could involve thousands, or even tens of thousands, of injured or 
ill victims.
    \4\ A standard of care is the diagnostic and treatment process that 
a provider should follow for a certain type of patient or illness, or 
certain clinical circumstances. It is how similarly qualified health 
care providers would manage the patient's care under the same or 
similar circumstances.
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    Following a mass casualty event, health care systems would need the 
ability to ``surge,'' that is, to adequately care for a large number of 
patients or patients with unusual or highly specialized medical needs. 
Providing such care would require the allocation of scarce resources 
and could occur outside of hospitals and other normal health care 
delivery sites. Through literature reviews and interviews with experts 
and professional associations, we identified four key components 
related to preparing for medical surge in a mass casualty event: (1) 
Increasing hospital capacity, including beds, workforce, equipment, and 
supplies; (2) identifying and operating alternate care sites \5\ when 
hospital capacity is overwhelmed; (3) registering and credentialing 
volunteer medical professionals; and (4) planning for appropriate 
altered standards of care \6\ in order to save the most lives in a mass 
casualty event.
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    \5\ Alternate care sites deliver medical care outside of hospital 
settings for patients who would normally be treated as inpatients.
    \6\ The term ``altered standards'' generally means a shift to 
providing care and allocating scarce equipment, supplies, and personnel 
in a way that saves the largest number of lives, in contrast to the 
traditional focus of treating the sickest or most injured patients 
first. For example, it could mean applying principles of field triage 
to determine who gets what kind of care, changing infection control 
standards to permit group isolation rather than single-person isolation 
units, changing who provides various kinds of care, or changing privacy 
and confidentiality protections temporarily.
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    Federal and State entities both play roles in preparing for 
emergency preparedness. The Department of Homeland Security (DHS) has 
the overall Federal responsibility under the Homeland Security Act of 
2002 for managing National emergency preparedness.\7\ In December 2006, 
the Congress passed the Pandemic and All-Hazards Preparedness Act 
(PAHPA). PAHPA designated the Secretary of Health and Human Services as 
the lead official for all Federal public health and medical responses 
to public health emergencies, including medical surge.\8\ Under the 
Federal plan for responding to emergencies,\9\ States have 
responsibility for producing emergency preparedness plans in 
coordination with regional and local entities, and both DHS and the 
Department of Health and Human Services (HHS) are responsible for 
supporting their efforts. In addition, the Department of Defense (DOD) 
and the Department of Veterans Affairs (VA) are expected to assist 
State and local entities in emergencies. A DOD directive authorizes 
local military hospitals to coordinate with State and local entities to 
plan for emergency preparedness, and DOD hospitals are authorized to 
accept civilian patients in a mass casualty event.\10\ VA policies and 
procedures allow VA hospitals to participate in State and local 
emergency planning, and by statute VA may provide medical care to non-
veterans in a mass casualty event.
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    \7\ See Pub. L. No. 107-296, 116 Stat. 2135 (2002).
    \8\ Pub. L. No. 109-417,  101, 120 Stat. 2831, 2832 (2006) 
(codified at 42 U.S.C.  300hh).
    \9\ The National Response Framework details the missions, policies, 
structures, and responsibilities of Federal agencies for coordinating 
resource and programmatic support to States, Tribes, and other Federal 
agencies.
    \10\ DOD Directive 3025.1, Military Support to Civil Authorities  
4.6.1.2 and 4.5.1 (Jan. 15, 1993).
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    My statement today is based largely on our June 2008 report 
entitled Emergency Preparedness: States Are Planning for Medical Surge, 
but Could Benefit from Shared Guidance for Allocating Scare Medical 
Resources \11\ and includes some updated information. In the June 2008 
report, we examined the following questions: (1) What assistance has 
the Federal Government provided to help States prepare their regional 
and local health care systems for medical surge in a mass casualty 
event? (2) What have States done to prepare for medical surge in a mass 
casualty event? (3) What concerns have States identified as they 
prepare for medical surge in a mass casualty event?
---------------------------------------------------------------------------
    \11\ GAO, Emergency Preparedness: States Are Planning for Medical 
Surge, but Could Benefit from Shared Guidance for Allocating Scare 
Medical Resources, GAO-08-668 (Washington, DC: June 13, 2008).
---------------------------------------------------------------------------
    In carrying out the work for our June 2008 report examining what 
assistance the Federal Government provided to States to help them 
prepare their regional and local health care systems for medical surge 
in a mass casualty event, we reviewed and analyzed National strategic 
planning documents. We also analyzed reports related to medical surge 
capacity issued by various entities, including the Agency for 
Healthcare Research and Quality (AHRQ), Centers for Disease Control and 
Prevention (CDC), Office of the Assistant Secretary for Preparedness 
and Response (ASPR), and the Joint Commission.\12\ In addition, we 
obtained and reviewed documents from ASPR to determine the amount of 
funds awarded to States through its Hospital Preparedness Program's 
cooperative agreements. We also interviewed officials from ASPR, CDC, 
and DHS to identify and document criteria and guidance given to States 
to plan for medical surge. To determine what States had done to prepare 
for medical surge in a mass casualty event, we obtained and analyzed 
the 2006 and 2007 ASPR Hospital Preparedness Program cooperative 
agreement applications and 2006 mid-year progress reports (the most 
current available information at the time of our data collection for 
the June 2008 report)\13\ for the 50 States.\14\ We also reviewed the 
15 sentinel indicators from these reports.\15\ Although ASPR's 2006 
guidance for these mid-year progress reports did not provide specific 
criteria with which to evaluate recipients' performance on these 
sentinel indicators, we identified criteria to analyze the data 
provided for 5 of the indicators related to one of four key 
components--hospital capacity--from either ASPR's previous program 
guidance or DHS guidance.\16\ In addition, we obtained and reviewed 20 
States' emergency preparedness planning documents relating to medical 
surge and interviewed officials from these States responsible for 
planning for medical surge. We selected the 20 States by identifying 2 
States from each of the 10 HHS geographic regions--one with the most 
ASPR Hospital Preparedness Program funding and one with the least 
funding. These selection criteria allowed us to take into account 
population (program funding was awarded using a formula including, in 
part, population), geographic dispersion, and different geographic risk 
factors, such as the potential for hurricanes, tornadoes, or 
earthquakes. We obtained and reviewed DOD and VA policies and 
interviewed officials regarding their participation with State and 
local entities in emergency preparedness planning and response. To 
determine what concerns States identified as they prepared for medical 
surge, we interviewed emergency preparedness officials from the 20 
States on their efforts related to four key components. We also asked 
what further assistance States might need from the Federal Government 
to help prepare their health care systems for medical surge. The 
information from these interviews is intended to provide a general 
description of what the 20 States have done to prepare for medical 
surge and is not generalizable to all 50 States. We conducted the 
performance audit for the June 2008 report from May 2007 through May 
2008, and updated certain information on the status of HHS's actions to 
respond to our recommendations by interviewing an HHS official, in 
accordance with generally accepted Government auditing standards. Those 
standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives. A detailed explanation of 
our methodology is included in our June 2008 report.
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    \12\ The Joint Commission is an independent, non-profit 
organization that evaluates and accredits more than 15,000 U.S. health 
care organizations and programs, including DOD and VA hospitals.
    \13\ The 2006 program year for the Hospital Preparedness Program 
was September 1, 2006, to August 31, 2007. The 2007 program year was 
September 1, 2007, to August 8, 2008.
    \14\ While the Hospital Preparedness Program awards funds annually 
to 62 entities--the 50 States; 4 municipalities, including the District 
of Columbia; 5 U.S. territories; and 3 Freely Associated States of the 
Pacific--we limited our review to the 50 States.
    \15\ Sentinel indicators are smaller component tasks of critical 
benchmarks, which measure program capacity-building efforts such as 
purchasing equipment and supplies and acquiring personnel. For example, 
for the benchmark ``Surge Capacity; Beds,'' one of the sentinel 
indicators is the number of additional hospital beds for which a 
recipient could make patient care available within 24 hours. ASPR 
requires that States report on 15 sentinel indicators.
    \16\ Two of the 15 indicators--total number of hospitals State-wide 
and total population State-wide--were used as denominators to analyze 
the 5 indicators.
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    In brief, we found that the Federal Government provided funding, 
guidance, and other assistance to help States prepare for medical surge 
in a mass casualty event. From fiscal years 2002 to 2007, the Federal 
Government awarded the States about $2.2 billion through ASPR's 
Hospital Preparedness Program to support activities to meet their 
preparedness priorities and goals, including medical surge. Further, we 
reported that the Federal Government developed, or contracted with 
experts to develop, guidance that was provided for States to use when 
preparing for medical surge and that ASPR project officers and CDC 
subject matter experts were available to provide assistance to States 
on issues related to medical surge. In reporting on State activities, 
we found that many States had made efforts related to three of the key 
components of medical surge, that is, increasing hospital capacity, 
planning for alternate care sites, and developing electronic medical 
volunteer registries, but fewer had addressed the fourth component, 
planning for altered standards of care. For example, in our 20-State 
review, we found that all were developing bed reporting systems to 
increase hospital capacity and 18 reported that they were in the 
process of selecting alternate care sites that used either fixed or 
mobile medical facilities. However, fewer of the States--7 of the 20--
had adopted or were drafting altered standards of medical care to be 
used in response to a mass casualty event. In reporting on concerns 
States identified as they prepared for medical surge, we found that 
State officials in the 20 States we surveyed reported that they 
continued to face challenges related to all four key components of 
medical surge. For example, some States reported that although they 
could increase numbers of hospital beds in a mass casualty event, they 
were concerned about staffing those beds because of current shortages 
in medical professionals, and some States reported that they had not 
begun work on altered standards of care guidelines, or had not 
completed drafting guidelines, because of the difficulty of addressing 
the medical, ethical, and legal issues involved in making life-or-death 
decisions in advance of a disaster about which patients would get or 
lose access to scarce resources.
    To further assist States in determining how they will allocate 
scarce medical resources in a mass casualty event, we recommended that 
the Secretary of HHS ensure that the department serve as a 
clearinghouse for sharing among the States altered standards of care 
guidelines that have been developed by individual States or medical 
experts. In commenting on a draft of our report in May 2008, HHS, DHS, 
DOD, and VA concurred with our findings. HHS was silent regarding our 
recommendation. However, in October 2009, an HHS official reported that 
the agency was designing a web portal to serve as a clearinghouse on 
preparedness and response, with an emphasis on the allocation of scarce 
medical resources, in part as a result of GAO's recommendation. In 
January 2010, an HHS official reported that efforts to design and 
develop the web portal were continuing.
the federal government has provided states with funding, guidance, and 
             other assistance to prepare for medical surge
    In June 2008, we reported that from fiscal years 2002 through 2007, 
HHS awarded States about $2.2 billion through ASPR's Hospital 
Preparedness Program \17\ to support activities to strengthen their 
hospital emergency preparedness capabilities, including medical surge 
goals and priorities.\18\ ASPR's 2007 Hospital Preparedness Program 
guidance specifically authorized States to use funds on activities such 
as the development of a fully operational electronic medical volunteer 
registry and the establishment of alternate care sites. We cannot 
report State-specific funding for the four key components of medical 
surge because State expenditure reports did not disaggregate the dollar 
amount spent on specific activities related to these components. During 
fiscal years 2003 through 2007, DHS's Homeland Security Grant Program 
also awarded the States funds that were used for a broad variety of 
emergency preparedness activities and may have included medical surge 
activities. However, most of these DHS grant funds were not targeted to 
medical surge activities, and States do not report the dollar amounts 
spent on these activities.
---------------------------------------------------------------------------
    \17\ An additional $218 million was provided to four large 
municipalities, five U.S. territories, and three Freely Associated 
States of the Pacific for a total of approximately $2.5 billion. Over 
the 2-year period, fiscal years 2004 and 2005, HHS also awarded an 
additional $200,000 to 48 States for electronic medical volunteer 
registries development through this program.
    \18\ Since January 2006, HHS also had awarded the 62 recipients an 
additional $400 million in two phases and a supplement to prepare for a 
pandemic influenza outbreak. The funds were awarded to accelerate their 
current planning efforts for an influenza pandemic and to exercise 
their plans. These funds included $75 million in August 2007 that could 
be used, in part, to develop pandemic alternate care sites and to 
conduct medical surge exercises.
---------------------------------------------------------------------------
    The Federal Government developed, or contracted with experts to 
develop, guidance for States to use in preparing for medical surge. DHS 
developed overarching guidance, including the National Preparedness 
Guidelines and the Target Capabilities List. The National Preparedness 
Guidelines describes the tasks needed to prepare for a medical surge 
response to a mass casualty event, such as a bioterrorist event or 
natural disaster, and establishes readiness priorities, targets, and 
metrics to align the efforts of Federal, State, local, Tribal, private-
sector, and nongovernmental entities. The Target Capabilities List 
provides guidance on building and maintaining capabilities, such as 
medical surge, that support the National Preparedness Guidelines. The 
medical surge capability includes activities and critical tasks needed 
to rapidly and appropriately care for the injured and ill from mass 
casualty events and to ensure that continuity of care is maintained for 
non-incident-related injuries or illnesses.\19\ In addition, ASPR 
provided States with specific guidance related to preparing for medical 
surge in a mass casualty event, such as annual guidance for its 
Hospital Preparedness Program cooperative agreements, guidance for 
developing electronic medical volunteer registries, and guidance to 
develop a hospital bed tracking system. For example, ASPR's electronic 
medical volunteer registries guidelines provide States with common 
definitions, standards, and protocols, which can aid in forming a 
National network to facilitate the deployment of medical volunteers for 
any emergency among States.
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    \19\ For example, one of the activities is to receive and treat 
surge casualties. One of the critical tasks associated with this 
activity is to ensure adequacy of medical equipment and supplies in 
support of immediate medical response operations and for restocking 
requested supplies and equipment.
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    Additionally, we reported that HHS worked through AHRQ and 
contracted with non-Federal entities to develop publications for States 
to use when preparing for medical surge. For example, AHRQ published 
the document Mass Medical Care with Scarce Resources: A Community 
Planning Guide to provide States with information that would help them 
in their efforts to prepare for medical surge, such as specific 
circumstances they may face in a mass casualty event. This publication 
notes that a State may be faced with allocating medical resources 
during a mass casualty event, such as determining which patients will 
have access to mechanical ventilation. The publication recommends that 
the States develop decision-making guidelines on how to allocate these 
medical resources. To support States' efforts to prepare for medical 
surge, the Federal Government also provided other assistance, such as 
conferences and electronic bulletin boards for States to use in 
preparing for medical surge. For example, States were required to 
attend annual conferences for Hospital Preparedness Program cooperative 
agreement recipients, where ASPR provided forums for discussion of 
medical surge issues. Furthermore, ASPR project officers and CDC 
subject matter experts were available to provide assistance to States 
on issues related to medical surge. For example, CDC's Division of 
Healthcare Quality Promotion developed cross-sector workshops for local 
communities to bring their emergency management, medical, and public 
health officials together to focus on emergency planning issues, such 
as developing alternate care sites. A detailed list of Federal guidance 
and conferences is included in our June 2008 report.
 many states have made efforts to increase hospital capacity, plan for 
    alternate care sites, and develop electronic medical volunteer 
    registries, but fewer have planned for altered standards of care
    In June 2008 we reported that States were making efforts to expand 
hospital capacity. We found that more than half of the States met or 
were close to meeting the criteria for the five surge-related sentinel 
indicators for hospital capacity that we reviewed from the Hospital 
Preparedness Program 2006 mid-year progress reports,\20\ the most 
recent available data at the time of our analysis for the June 2008 
report.\21\ Twenty-four of the States reported that all of their 
hospitals were participating in the State's program funded by the ASPR 
Hospital Preparedness Program, with another 14 States reporting that 90 
percent or more of their hospitals were participating. Forty-three of 
the 50 States had increased their hospital capacity by ensuring that at 
least one health care facility in each defined region could support 
initial evaluation and treatment of at least 10 patients at a time 
(adult and pediatric) in negative pressure isolation \22\ within 3 
hours of an event. Regarding individual hospitals' isolation 
capabilities, 32 of the 50 States met the requirement that all 
hospitals in the State that participate in the Hospital Preparedness 
Program be able to maintain at least one suspected highly infectious 
disease case in negative pressure isolation; another 10 States had that 
capability in 90 to 99 percent of their participating hospitals. 
Thirty-seven of the 50 States reported meeting the criteria that within 
24 hours of a mass casualty event, their hospitals would be able to add 
enough beds to provide triage treatment and stabilization for another 
500 patients per million population; another 4 States reported that 
their hospitals could add enough beds for from 400 to 499 patients per 
million population. Finally, 20 of the 50 States reported that all 
their participating hospitals had access to pharmaceutical caches that 
were sufficient to cover hospital personnel (medical and ancillary), 
hospital-based emergency first responders, and family members 
associated with their facilities for a 72-hour period; another 6 States 
reported that from 90 to 99 percent of their participating hospitals 
had sufficient pharmaceutical caches.
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    \20\ The 2006 program year was from September 1, 2006, to August 
31, 2007; therefore, information provided in the mid-year progress 
reports was reported as of March 2007.
    \21\ Four of the States we reviewed provided sentinel indicator 
information as of April 2007, one State as of August 2007, and another 
State as of September 2007.
    \22\ Negative pressure isolation rooms maintain a flow of air into 
the room to ensure that contaminants and pathogens cannot escape from 
the room to other parts of the facility and to protect the health of 
workers and other patients.
---------------------------------------------------------------------------
    We also reported in 2008 that in a further review of 20 States, all 
20 States reported that they had developed or were developing bed 
reporting systems to track their hospital capacity--the first of four 
key components related to preparing for medical surge. Eighteen of the 
20 States reported that they had systems in place that could report the 
number of available hospital beds within the State. All 18 of these 
States reported that their systems met ASPR Hospital Available Beds for 
Emergencies and Disasters (HAvBED) standards.\23\ The two States that 
reported that they did not have a system that could meet HAvBED 
requirements said that they would meet the requirements by August 8, 
2008.\24\ We also reported that of the 10 States with DOD hospitals, 9 
reported coordinating with DOD hospitals to plan for emergency 
preparedness and increase hospital capacity and 8 reported that DOD 
hospitals in their State would accept civilian patients in the event of 
a mass casualty event if resources were available.\25\ Additionally, of 
the 19 States that have VA hospitals, all reported that at least some 
of the VA hospitals took part in the States' hospital preparedness 
programs or were included in planning and exercises for medical 
surge.\26\ VA officials Stated that individual hospitals cannot 
precommit resources--specific numbers of beds and assets--for planning 
purposes, but can accept nonveteran patients and provide personnel, 
equipment, and supplies on a case-by-case basis during a mass casualty 
event.\27\ Twelve of the 19 States reported that VA hospitals would 
accept or were likely to accept nonveteran patients in the event of a 
medical surge if space were available and veterans' needs had been met, 
and one State reported that some of its VA hospitals would take 
nonveteran patients and others would not.
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    \23\ Among other standards, HAvBED systems are required to report 
on seven categories of staffed available beds. The seven bed categories 
are intensive care, medical and surgical, burn, pediatric intensive 
care, pediatric, psychiatric, and negative pressure isolation. HAvBED 
systems are also required to report on emergency department diversions, 
decontamination facilities available, and ventilators available. ASPR 
allows each State to use Hospital Preparedness Program funds to develop 
its own bed tracking system as long as the system meets HAvBED 
requirements.
    \24\ ASPR required all recipients to complete the development of 
their bed tracking system by August 8, 2008.
    \25\ DOD Directive 3025.1, section 4.5.1 authorizes military 
officials to take necessary actions to respond to civilian requests for 
assistance in emergencies, which may include accepting civilian 
patients. This decision can be authorized by DOD or, in cases of urgent 
need, by the commander of the local military hospital.
    \26\ VA is authorized to furnish hospital care or medical services 
as a humanitarian service to non-VA beneficiaries in emergency cases. 
See 38 U.S.C.  1784; 38 CFR  17.37, 17.43, 17.95, 17.102. VA is also 
authorized to provide care and services during certain disasters and 
emergencies. See 38 U.S.C.  1785; 38 CFR  17.86.
    \27\ According to a VA General Counsel memorandum (Guidance on 
Entering into Mutual Aid Agreements, July 23, 2003), hospitals can also 
enter into mutual aid agreements in which VA hospitals and local 
entities agree to assist each other during disasters and emergencies. 
These agreements often include provisions to accept patients from other 
hospitals if the transferring hospital has an overwhelming number of 
patients or if the transferring facility does not have the resources 
for patients who require specialized medical treatment. However, these 
mutual aid agreements must state that the agreement is limited by 
certain VA obligations that may take precedence over the agreement to 
assist local hospitals during an emergency, such as VA's obligations 
under the National Disaster Medical System and its obligations to 
assist DOD during a time of war or National emergency.
---------------------------------------------------------------------------
    We further reported in June 2008 that 18 of the 20 States reported 
that they were in the process of selecting alternate care sites, and 
the two remaining States reported that they were in the early planning 
stages in determining how to select sites. Of the 18 States, 10 
reported that they had also developed plans for equipping and staffing 
some of the sites. For example, one State had developed standards and 
guidance for counties to use when implementing fixed alternate care 
sites and had stockpiled supplies and equipment for these sites. 
Another State, which expects significant transportation difficulties 
during a natural disaster, had acquired six mobile medical tent 
facilities of either 20 or 50 beds that were stored at hospital 
facilities across the State. One of the two States that were in the 
early planning stages was helping local communities formalize site 
selection agreements, and the second State had drafted guidance for 
alternate care sites.
    Our June 2008 report also noted that 15 of the 20 States reported 
that they had begun registering medical volunteers and identifying 
their medical professions in an electronic registry, and the remaining 
5 States were developing their electronic registries and had not 
registered any volunteers. Officials from 4 of the 5 remaining States 
that had not begun registering volunteers reported that they 
anticipated registering them. An official from the other State reported 
that State officials did not know when they would begin to register 
volunteers. Of the 15 States that reported they were registering 
volunteers, 12 reported they had begun to verify the volunteers' 
medical qualifications, though few had conducted the verification to 
assign volunteers to the highest level, Level 1. At Level 1, all of a 
volunteer's medical qualifications, which identify his or her skills 
and capabilities, have been verified and the volunteer is ready to 
provide care in any setting, including a hospital.
    In our 20-State review of efforts related to the fourth key 
component, we reported that 7 States had adopted or were drafting 
altered standards of care for specific medical issues. Three of the 7 
States had adopted some altered standards of care guidelines. For 
example, one State had prepared a standard of care for the allocation 
of ventilators in an avian influenza pandemic, which one State official 
reported would also be applicable during other types of 
emergencies.\28\ Another State issued guidelines in February 2008 for 
allocating scarce medical resources in a mass casualty event that call 
for suspending or relaxing State laws covering medical care and for 
explicit rationing of health care to save the most lives, and required 
that the same allocation guidelines be used across the State. Of the 13 
States that had not adopted or drafted altered standards of care, 11 
States were beginning discussions with State stakeholders, such as 
medical professionals and lawyers, related to altered standards of 
care, and 2 States had not addressed the issue. One State reported that 
its State health department planned to establish an ethics advisory 
board to begin discussion on altered standards of care guidelines. 
Another State had developed a ``white paper'' discussing the need for 
an altered standards of care initiative and planned to fund a symposium 
to discuss this initiative.
---------------------------------------------------------------------------
    \28\ A ventilator mechanically moves oxygen into and out of the 
lungs of a patient who is physically unable to breathe on his or her 
own, or whose breathing is insufficient to maintain life.
---------------------------------------------------------------------------
   states reported concerns related to all four key components when 
                      preparing for medical surge
    In June 2008, we reported that even though States had made efforts 
to increase hospital capacity, provide care at alternate care sites, 
identify and use medical volunteers, and develop appropriate altered 
standards of care, they expressed concerns related to all four of these 
key components of medical surge.
    Hospital capacity concerns. We reported that State officials raised 
several concerns related to their ability to increase hospital 
capacity, including maintaining adequate staffing levels during mass 
casualty events, a problem that was more acute in rural communities. 
While 19 of 20 States we surveyed reported that they could increase 
numbers of hospital beds in a mass casualty event,\29\ some State 
officials were concerned about staffing these beds because of current 
shortages in medical professionals, including nurses and physicians. 
Some State officials reported that their States faced problems in 
increasing hospital capacity because many of their rural areas had no 
hospital or small numbers of medical providers. For example, officials 
from a largely rural State reported that in many of the State's 
medically underserved areas hospitals currently have vacant beds 
because they cannot hire medical professionals to staff them.
---------------------------------------------------------------------------
    \29\ Officials from the remaining State reported that they did not 
know how many beds were available State-wide above the current daily 
staffed bed capacity.
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    Alternate care site concerns. Some State officials reported that it 
was difficult to identify appropriate fixed facilities for alternate 
care sites. Officials from two States reported that some small, rural 
communities had few facilities that would be large enough to house an 
alternate care site. Officials from some States also reported that some 
of the facilities that could be used as alternate care sites had 
already been allocated for other emergency uses, such as emergency 
shelters. Some State officials also reported concerns about 
reimbursement for medical services provided at alternate care sites, 
which are not accredited health care facilities, and concerns regarding 
how certain Federal laws and regulations that relate to medical care 
would apply during a mass casualty event for care provided at 
alternative care sites.
    Electronic medical volunteer registry concerns. We reported that 
some States reported that medical volunteers might be reluctant to join 
a State electronic medical volunteer registry if it is used to create a 
National medical volunteer registry. PAHPA requires ASPR to use the 
State-based registries to create a National database. According to 
State officials, some volunteers do not want to be part of a National 
database because they are concerned that they might be required to 
provide services outside their own State. Officials from one State 
reported that since PAHPA was enacted, recruiting of medical volunteers 
was more difficult and that the Federal Government should clarify 
whether National deployment is a possibility. ASPR officials said that 
they would not deploy medical volunteers nationally without working 
through the States. Additionally, some States expressed concerns about 
coordination among programs that recruit medical volunteers for 
emergency response. Officials from one State reported that Federal 
volunteer registration requirements for the Medical Reserve Corps (MRC) 
\30\ and the electronic medical volunteer registry programs had not 
been coordinated, resulting in duplication of effort for volunteers. 
Officials from a second State reported that a volunteer for one program 
that recruits medical volunteers is often a potential volunteer for 
another such program, which could result in volunteers being double-
counted. This may cause staffing problems in the event of an emergency 
when more than one volunteer program is activated.
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    \30\ MRC is a Federal program within the U.S. Surgeon General's 
Office, which is in HHS. MRC units are community-based and organize and 
utilize volunteers to, among other things, prepare for, and respond to 
emergencies. MRC volunteers include medical and public health 
professionals as well as other community members, such as interpreters 
and legal advisers.
---------------------------------------------------------------------------
    Altered standards of care concerns. Some State officials reported 
that they had not begun work on altered standards of care guidelines, 
or had not completed drafting guidelines, because of the difficulty of 
addressing the medical, ethical, and legal issues involved. For 
example, in 2005 HHS estimated that in a severe influenza pandemic 
almost 10 million people would require hospitalization,\31\ which would 
exceed the current capacity of U.S. hospitals and necessitate difficult 
choices regarding rationing of resources.\32\ HHS also estimated that 
almost 1.5 million of these people would require care in an intensive 
care unit and about 740,000 people would require mechanical 
ventilation. Even with additional stockpiles of ventilators, there 
would likely not be a sufficient supply to meet the need. Since some 
patients could not be put on ventilators, and others would be removed 
from ventilators, standards of care would have to be altered and 
providers would need to determine which patients would receive them. In 
addition, some State officials reported that medical volunteers are 
concerned about liability issues in a mass casualty event. 
Specifically, State officials reported that hospitals and medical 
providers might be reluctant to provide care during a mass casualty 
event, when resources would be scarce and not all patients would be 
able to receive care consistent with established standards. According 
to these officials, these providers could be subject to liability if 
decisions they made about altering standards of care resulted in 
negative outcomes. For example, allowing staff to work outside the 
scope of their practice, such as allowing nurses to diagnose and write 
medical orders, could place these individuals at risk of liability.
---------------------------------------------------------------------------
    \31\ By comparison, seasonal influenza in the United States 
generally results in 200,000 hospitalizations annually.
    \32\ Department of Health and Human Services, HHS Pandemic 
Influenza Plan (Washington, DC, November 2005).
---------------------------------------------------------------------------
    While some States reported using AHRQ's Mass Medical Care with 
Scarce Resources: A Community Planning Guide to assist them as they 
developed altered standards of care guidelines, some States also 
reported that they needed additional assistance. States said that to 
develop altered standards of care guidelines they must conduct 
activities such as collecting and reviewing published guidance and 
convening experts to discuss how to address the medical, ethical, and 
legal issues that could arise during a mass casualty event. Four States 
reported that, when developing their own guidelines on the allocation 
of ventilators, they were using guidance from another State, which had 
estimated that a severe influenza pandemic would require nearly nine 
times the State's current capacity for intensive care beds and almost 
three times its current ventilator capacity, requiring the State to 
address the rationing of ventilators. In March 2006 the State convened 
a work group to consider clinical and ethical issues in the allocation 
of mechanical ventilators in an influenza pandemic.\33\ The State 
issued guidelines on the rationing of ventilators that include both a 
process and an evaluation tool to determine which patients should 
receive mechanical ventilation. The guidelines note that the 
application of this process and evaluation tool could result in 
withdrawing a ventilator from one patient to give it to another who is 
more likely to survive--a scenario that does not explicitly exist under 
established standards of care. Additionally, some States suggested that 
the Federal Government could help their efforts in several ways, such 
as by convening medical, public health, and legal experts to address 
the complex issues associated with allocating scarce resources during a 
mass casualty event, or by developing demonstration projects to reveal 
best practices employed by the various States.
---------------------------------------------------------------------------
    \33\ The group brought together experts in law, medicine, policy 
making, and ethics with representatives from medical facilities and 
city, county, and State government.
---------------------------------------------------------------------------
    In May 2008, the Task Force for Mass Critical Care, consisting of 
medical experts from both the public and the private sectors, provided 
guidelines for allocating scarce critical care resources in a mass 
casualty event that have the potential to assist States in drafting 
their own guidelines. The task force's guidelines, which were published 
in a medical journal,\34\ provide a process for triaging patients that 
includes three components--inclusion criteria, exclusion criteria, and 
prioritization of care. The exclusion criteria include patients with a 
high risk of death, little likelihood of long-term survival, and a 
corresponding low likelihood of benefit from critical care resources. 
When patients meet the exclusion criteria, critical care resources may 
be reallocated to patients more likely to survive.
---------------------------------------------------------------------------
    \34\ The task force included officials from DHS, HHS, ASPR, CDC, 
DOD, and VA. See Asha V. Devereaux et al., ``Definitive Care for the 
Critically Ill During a Disaster: A Framework for Allocation of Scarce 
Resources in Mass Critical Care: From a Task Force for Mass Critical 
Care Summit Meeting, January 26 to 27, 2007, Chicago, Il.,'' Chest 
(2008): 133, 51-66.
---------------------------------------------------------------------------
                        concluding observations
    In our June 2008 report, we noted that though States had begun 
planning for medical surge in a mass casualty event, only 3 of the 20 
States in our review had developed and adopted guidelines for using 
altered standards of care. HHS has provided broad guidance that 
establishes a framework and principles for States to use when 
developing their specific guidelines for altered standards of care. 
However, because of the difficulty in addressing the related medical, 
ethical, and legal issues, many States were only beginning to develop 
such guidelines for use when there are not enough resources, such as 
ventilators, to care for all affected patients. In a mass casualty 
event, such guidelines would be a critical resource for medical 
providers who may have to make repeated life-or-death decisions about 
which patients get or lose access to these resources--decisions that 
are not typically made in routine circumstances. Additionally, these 
guidelines could help address medical providers' concerns about ethics 
and liability that may ensue when negative outcomes are associated with 
their decisions. In its role of assisting States' efforts to plan for 
medical surge, HHS has not collected altered standards of care 
guidelines that some States and medical experts have developed and made 
them available to other States. Once a mass casualty event occurs, 
difficult choices will have to be made, and the more fully the issues 
raised by such choices are discussed prior to making them, the greater 
the potential for the choices to be ethically sound and generally 
accepted.
    Mr. Chairman, this concludes my prepared statement. I would be 
happy to answer any questions you or other Members of the subcommittee 
may have.

    Mr. Carney. Thank you for your testimony, and I would like 
to thank each of the witnesses for their testimony. We will now 
go to the questions. Mr. Bilirakis and I will ask questions for 
5 minutes each to the panel alternating back and forth, and we 
will take as long as it takes. I will start, this question is 
for Dr. Jolly and Dr. Pane both. How do you see, and I know you 
mentioned this in your opening statements, but how do you see 
DHS and HHS working together in practical terms, something 
beyond the National Response Framework? I know how it is 
supposed to work on paper but in practical terms, how do you 
see it?
    Dr. Jolly. I will start on a very practical level. Part of 
this is driven really by the day-to-day workings between the 
department, between the part of DHS, the operations director at 
FEMA, and parts of HHS, ASPR, CDC and other parts that really 
work through issues on a day-to-day basis that have not risen 
to crisis levels or result in planning or preparedness or 
exercises. For large-scale events, it is well recognized that 
well worked out that DHS is the lead for overall management and 
the health and medical aspects are led by HHS, but they are 
obviously interplayed among those that we facilitate. It is 
hard to work out all the details of that over time, but as we 
work more and more on this it gets smoother during incidents, 
and I think each one of these teaches us what is going to 
happen on the next one. Dr. Pane.
    Dr. Pane. Let me just add, Mr. Chairman, that I couldn't 
agree more with what Dr. Jolly is saying. Having been an ER doc 
myself for a lot of years and a hospital executive and State 
health department director who got these grants, I think one of 
the most important things we can do in Washington is to walk 
the talk. We ask our wardees to coordinate and drill and work 
together, and I think we need to do the same thing, so it is 
very important that we do that. We have a lot of activities 
going on with the DHS, as well as within our own department in 
CDC trying to be sure we are coordinated and working through 
issues proactively. There is regular contact, as Dr. Jolly 
alluded to, because the Office of Health Affairs and various 
parts of HHS on a host of things.
    Certainly in times of response as I allude to in my 
testimony we are in the command centers together working very 
closely with our regional and emergency coordinators, with 
Homeland Security officials in the State, as well as in the 
National center during a disaster. In addition, we have a 
working group that we are part of that is working to coordinate 
grant guidance and others things, so we have a group that is 
looking at the MRS system, looking at UASI dollars, looks at 
the CDC TEF dollars, looks at our SUP dollars, and tries to 
take a look at are we doing a coordinated grant notice, 
coordinated metrics, is it appearing to States that we are 
walking the talk.
    I know when I got those dollars, that is how I acted with 
them. I am glad to get them from various parts of the Federal 
Government, but it is your job at the State level or local 
level to make music in the orchestra. We are giving you 
sections. You need to make the music here locally. So it is 
very important. It is a job that is too important not to 
succeed in, so we take great pride in trying to work through 
some of those issues and make a more coordinated Government so 
we have a more effective response locally.
    Mr. Carney. What is the nature of your relationship beyond 
the National response plan? You talk about daily contacts. 
Characterize that, please.
    Dr. Jolly. With or without a document called the National 
Response Framework, which is obviously a very important 
document, on a daily basis we have, for instance, planning 
groups on anthrax response, on H1N1 response. Well before the 
beginning of this pandemic on a regular basis the interagency 
meetings among DHS, HHS, and all our other interagency partners 
happened on a very regular basis to plan for the various 
contingencies of a pandemic, and then on specific issues such 
as vaccine distribution or countermeasure distribution, or 
surveillance, different parts and different subject matter 
experts. The people on the ground who really know the most 
about these specific issues get together sometimes daily, 
sometimes weekly, go to meetings together, and not just for the 
sake of meetings but to really see how the assets that the DHS 
has and the assets that HHS has, and, most importantly, the 
assets that State and local officials have that are partially 
funded by the Federal Government and locally funded can work 
together.
    Mr. Carney. Ms. Bascetta, both DHS and HHS have surge 
responsibilities. How are they doing from GAO's perspective in 
coordinating those?
    Ms. Bascetta. This is a subject that we are still looking 
at, and specifically we have on-going work on lessons learned 
from the recent--the most recent response to the first two 
waves of the pandemic. We noted in our work on pan flu that 
clarification of the rules and relationships between those two 
departments in particular but also other Federal agencies and 
components within HHS is important to continue to work on and 
to refine. I have a couple of experiences with DHS and HHS in 
other work that I conducted. One was on the case of the 
tuberculosis traveler who boarded a plane and went overseas. 
There was actually a very successful story as result of that 
where CDC and Customs and Border Patrol Control with DHS kind 
of had a rocky start working together originally because they 
came at the problem from very diverse points of view.
    But they learned a tremendous amount through that 
experience, and I think it is that daily interaction, person to 
person, certainly not at the higher levels, that is important 
in forming the kinds of relationships we need to have 
successful response.
    Mr. Carney. I will explore that in my next question, but 
now Mr. Bilirakis for 5 minutes.
    Mr. Bilirakis. Thank you, Mr. Chairman. The first question 
is for Dr. Jolly. Is the medical community prepared if disaster 
or terrorism strikes as the title of this hearing offers, and 
also is the medical community capable of handling a 
bioterrorism attack such as anthrax or smallpox while 
concurrently responding to a pandemic? Won't the same resources 
that are currently stretched thin face even greater strain, and 
what needs to be done to make our preparedness better and how 
are we identifying existing gaps and capabilities and who is 
charged with correcting them?
    Dr. Jolly. That is a very comprehensive question. 
Hopefully, I can provide a very comprehensive answer. The 
medical community is a very broad community, and it is not just 
the emergency medical community or critical care community, but 
the broad medical community, including nursing, physician 
assistants, administrators, the public health community. You 
know, there are many, many large challenges that we could 
potentially face. I think the medical community still has work 
to do. There is still educational work. There is still training 
work. There is still planning and exercise work that the 
community needs to do to surge beyond the day-to-day hard work 
it is doing right now. These are not a group of people who are 
sitting still waiting for the next thing to happen.
    We are prepared in the mist of a pandemic were other things 
to happen. Our preparation continues for those. Our 
preparedness continues for those. Any concurrent hazards would 
be a challenge but those are things we think about. We never 
think about just doing one thing at a time. As we work through 
this, I think there are many things to work on, both 
coordination, which sounds a bit like a bureaucratic term, but 
it has real meaning, getting emergency preparedness, law 
enforcement, other critical infrastructures, together with the 
medical community to really broaden the definition of what 
health care surge really is beyond just the four walls of one 
or more hospitals.
    There is much more we can work on with you, and I think the 
models of the prior MMRS program, over 110 in the country, 
serve to model some of those workings locally, and I think we 
can broaden that Federally.
    Mr. Bilirakis. Would you like to add something, sir?
    Dr. Pane. Just briefly, I would add that as Dr. Jolly has 
said this is a complicated thing, and what we have tried to do 
over the years, and I have seen it myself as an ER doctors, and 
I am sure Til has as well, I think it has never been better but 
we still have a ways to go. I mean we have come a long, long 
way thanks to your support in Congress. Some of these dollars 
we have been able to put out to States, we really, I think, 
improved coordination and guidance. But the real action, I 
believe, is with State and localities and hospitals, docs, 
other health professionals, and also working with the emergency 
management community, police, fire, and others. A lot of that 
has happened through various trainings and exercises, which I 
think is the key.
    We contract for a couple of studies with the University of 
Pittsburgh Medical Center, the Center for Security, and they 
have looked at both our programs, and I think what they have 
said is the best thing that we have done and we should keep 
doing is getting people to work together, talk together, drill, 
exercise, training, increase that comfort level as the GAO 
said. That is, I think, key in disasters. Being able to respond 
to any hazard is having that experience of walking though the 
problem and actually taking real-life exercises, doing after-
action report, what happened, what we can do better. A lot of 
that goes on, and I think we are making tremendous headway, but 
we certainly have a way to go, sir.
    Mr. Bilirakis. Anyone else that would like to respond to 
that?
    Ms. Bascetta. I will just add two things. One very concrete 
thing is that our vaccine technology is very antiquated. We 
still have egg-based production and we really need to move 
forward on what is happening to develop cell-based technology 
so we can get vaccines produced much more quickly. The second 
thing is that the question is always how well are we prepared 
and prepared for what. We are always well prepared for what 
just happened, but it is hard to anticipate what is coming down 
the pike. As the Chairman said in his opening remarks, 
balancing the costs and benefits of that preparation is really 
a tough nut to crack. I would like to think about also building 
in resilience. You want to make the assumption that things are 
going to happen but they are, and figuring out the flexible 
ways to be resilient and to respond with minimizing the 
disaster is an important framework to begin focusing on.
    Mr. Bilirakis. Thank you. Dr. Jolly, given that the 
hospital preparedness is a local issue and that the Federal 
Government support this effort is provided by the Department of 
Health and Human Services, what role does the Office of Medical 
Readiness play in ensuring that hospitals are able to increase 
their surge capacity?
    Dr. Jolly. As you said, the primary funding and support for 
hospital preparedness resides within Health and Human Services, 
and they do quite a good job at that. As you know, FEMA has a 
number of grant and training programs, some of which are 
applicable simply to health care systems and more which are 
more broadly applicable across communities. One of the 
important roles of our office is to look at those grant 
functions to work with FEMA and to look at them from a health 
perspective. Our office is working with offices with ASPR, the 
Assistant Secretary for Preparedness Response, to try to 
coordinate some of those grant time lines, some of the 
guidance, and try to make sure that the FEMA grant programs 
consider health aspects of what they are doing and tie better 
so that local officials, as Dr. Pane used to be, can make some 
sense out of the various pools of money that are coming to 
them.
    Mr. Bilirakis. Thank you. Thank you, Mr. Chairman.
    Mr. Carney. Okay. Ms. Bascetta, let us return to the line 
of questions from before. How is the coordination going? You 
were talking about the tuberculosis case. We seem to learn 
going forward after an event happens how to respond. Is that 
the best model?
    Ms. Bascetta. No, it certainly isn't but the reality is 
that 9/11 is still a relatively recent event, and we have 
learned a lot from it and from Katrina and from pan flu, and 
overcoming the silos within departments and across departments 
is something that really requires practice. I think we have 
learned the lesson of practice, as Mr. Pane said. Many experts 
who have studied disaster response have pointed out that 
getting to know each other on the day of the response isn't 
going to work, and I think the lesson of exercising is pretty 
clear.
    Mr. Carney. This is for everybody here, including Ms. 
Fitzgerald. We are going to get to you, don't worry. When 
talking about exercising--as somebody who has been in the 
military for a lot of years now, we exercise a lot of different 
scenarios, a lot of different things. We do it all the time 
when we train. How often do you exercise? Is the exercise 
adequate? Is it reflective of reality? Those are the things 
that we are really concerned with. So, Dr. Jolly, why don't you 
start and we will just work down the table?
    Dr. Jolly. I think that exercising just for exercising's 
sake is not a good idea. I think we are increasing our number 
of exercises. FEMA, the National Exercise Division within FEMA 
maintains the Homeland Security Exercise and Evaluation 
Program, which is an interagency effort to coordinate those 
exercises. I think as we move toward more realistic exercises, 
it is important to exercise sometimes to a point of failure in 
the exercise and to have the leaders that are in those 
exercises go through very difficult rather than scripted I know 
what I am going to do situations. I think the leadership of the 
National Exercise Division is thinking about--is moving in that 
direction as all of us in Government from principals, the 
Cabinet members, down through the operators in the departments.
    Dr. Pane. The training aspect and exercise is the core of 
the Hospital Preparedness Program, and we are looking for 
hospitals to actually work together. This is the Hospital 
Disaster Plan we are talking about. This is actually groups of 
hospitals or health facilities in a region along with other 
professionals in the larger emergency management community 
working together. We have specific exercise requirements, and a 
lot of us are geared toward that regional concept as well as 
State-wide activities in the larger emergency management 
community with DHS and FEMA. There is a lessons-learned entity 
through DHS called LLIS, Lessons Learned Information System, I 
believe, which we upload all these things, and we are trying to 
single out the health part of that and make it more easy to use 
and get that word out because it is probably the primary thing 
we can do.
    Those of you who watched the game last night in watching 
the defense, we do an all-hazards approach because we want to 
be ready for anything offense throws at us whether it is a 
chem, a bomb, pan flu, so that the core things of drilling and 
exercising together, the training aspects, the communication 
system, calling up volunteers, some of the same principles 
would be used for many things. We try to emphasize that and 
keep pushing it to get better to perform its metrics and work 
groups, NIMS requirements, the National Information Management 
System, we work with hospitals to enhance that. So a lot of 
that activity is going into exercises and making it better to 
get a better yield.
    Ms. Fitzgerald. There are so many opportunities for 
exercising across the State of Pennsylvania, both at the 
individual hospital level, at a county and municipal level, 
engaging the county and municipal emergency management engaging 
at a regional level and then obviously engaging at the State-
wide level. From a State health department perspective on a 
regular basis we are encouraging communications exercising so 
we are testing our 800 megahertz radio system. We are testing 
our ability to feed data into our facility's database so that 
we are prepared for something like the H1N1 event.
    We test our equipment so we purchase the portable 
hospitals. It is not rocket science to put up one of the 
portable hospitals but on a regular basis we need to pull them 
out and make sure that everything is still working, so we are 
exercising that. Ultimately, there are so many pieces of our 
all-hazards plan that need to be trained to an exercise that 
this is an on-going effort year after year after year to 
continue to work at the individual hospital level as well as at 
the regional level.
    Mr. Carney. What is your relationship with the Federal 
Government when you do these exercises?
    Ms. Fitzgerald. We absolutely report our exercises to the 
Federal Government.
    Mr. Carney. Do they participate? Is there any 
participation?
    Ms. Fitzgerald. Absolutely. They are always willing to come 
in and participate in our exercises, so at least once a year we 
probably have Federal representation at one of our exercises.
    Mr. Carney. Okay. We will get back to you. It is Mr. 
Bilirakis' turn.
    Mr. Bilirakis. Thank you, Mr. Chairman. This is for Dr. 
Jolly. The MMRS program supports the integration of emergency 
management, health, and medical systems into a coordinated 
response to mass casualty incidents caused by any hazard 
including pandemic influenza. Successful MMRS grantees reduced 
the consequences of a mass casualty incident during the initial 
period of response by having augmented existing local 
operational response systems before the incident occurs. How 
are we utilizing the MMRS system to respond to shortages in 
vaccine and personal protective equipment such as the N95 
respirator masks?
    Dr. Jolly. Well, the MMRS system, as you know, has a long 
history of coordinated functions among the various services 
within a community. Over 100 communities are MMRS cities and 
work law enforcement, fire, EMS, and hospitals to create a 
coordinated local and then regional function. The specific 
shortages or potential shortfalls in some of the PPE and some 
of the pharmaceuticals are not really a function of the MMRS, 
but they are important in analyzing the needs for those and 
also sometimes in distributing. At least one of our MMRS 
jurisdictions asked to help with a local community vaccine 
distribution which they had expertise in Maine, I believe it 
was, to provide the services that a local college couldn't 
provide but they had people who needed a vaccine, so they do 
serve as a resource to provide those services when they are 
needed and then be prepared when large things happen.
    Mr. Bilirakis. Thank you. Dr. Pane, approximately 800,000 
doses of H1N1 vaccine were recalled last month. Most of these 
doses were used in young children ages 6 months through 3 years 
old. The reason for the recall was that tests show that the 
vaccine might not have been potent enough to protect against 
the virus. What caused this failure and how has it been 
corrected? Doesn't this error further strain existing medical 
surge capacity resources, and are we doing enough to protect 
our Nation's children, and all high-risk groups for that 
matter?
    Dr. Pane. I will have to get back to you on some of the 
details of that through our BARDA, Biomedical Advance Research 
and Development Authority, part of HHS and part of ASPR, that 
is really dealing with countermeasure development. I can tell 
you, Mr. Bilirakis, as Cynthia Bascetta mentioned, we are still 
dealing in a primary world of non-manufacturers, and we are 
still in an egg-based as opposed to cell-based technology. I 
know BARDA, a lot of their work has been geared toward 
expanding through contracts and incentives the manufacturing 
base to get more vaccine today and the, second, to move toward 
cell-based.
    In terms of H1N1, I think everybody in the room has 
probably read about the development was slowed. It didn't grow 
as fast. All viruses are a little different. While I think it 
turned out to be safe and effective and it is still being 
promoted--in fact, I was sitting, I think, in the hotel last 
night, and I saw a Pennsylvania about H1N1, to go get it, so we 
really work closely with State and local public health to 
recommend the use of that. I think the overwhelming evidence is 
the vaccine is safe. Certainly, this time around, I think 
without BARDA and the work HHS has done, it would have been 
even slower getting out. We always assume that something like 
this would happen overseas. We have had months to get ready and 
this happened in our back yard and we had to develop things 
rapidly, so I think all said and done the vaccine was gotten 
out as quickly as we could, and lucked out this wasn't a real 
serious virus.
    But your point is well taken. We need to improve our 
ability to manufacture vaccines quickly and safely get them 
out. The safety among children is key. In fact, we are dealing 
right now with--there is a commission on children disasters 
that have issued a number of recommendations that we are trying 
to incorporate into our guidance and other means, and certainly 
vaccine is one of them. So I think your question is timely and 
accurate and it is very important to the public that vaccines 
are safe and timely. I know as a father and as a local public 
health official myself that that was one of the key things that 
you want to pay a lot of attention to and do your best to 
advocate and I think our States are doing a good job with it 
and we need to continue that.
    Mr. Bilirakis. Thank you. Why don't I wait till the next 
round, Mr. Chairman?
    Mr. Carney. Dr. Pane, just in the last round of questions 
the LLIS was mentioned. Does HHS actually use the LLIS, the 
Lessons Learned Information System?
    Dr. Pane. We do, and I think we have agreed that this is 
the vehicle we want to use, and so we are going to work even 
harder to encourage hospitals to get this information put in 
and then to have a health section because it comes in all kinds 
of preparedness and disaster exercises, so it would be most 
helpful for health and medical. We are going to continue to 
promote that, so, yes, we believe we can use it. We also, of 
course, have other means of gathering best practices and having 
dialogue with our States, and I won't go into that now because 
I know your time is limited. But when I arrived, best practices 
identification and innovation was something I think we could do 
a better job of finding them, working with our States to 
recognize them, and promoting their adoption faster because 
there is great work going on, as we have seen here today, and 
we need to be sure those lessons learned when something goes 
wrong, but also when something needs happening or something 
innovative is happening around the country for a problem, we 
want others to know about it.
    Mr. Carney. Okay. I want to shift gears just a little bit 
now and talk about the altered standards of care crisis, 
whatever you want to call it, from all your perspectives. How 
do we address this, Dr. Jolly and Dr. Pane, in terms of medical 
surge? What are your perspectives on this?
    Dr. Jolly. I would acknowledge what our colleagues from GAO 
have found, and these are difficult issues. This is more as a 
position as a Homeland Security official to think that there 
are somewhat different standards or crisis standards in a 
large-scale incident than on a day-to-day basis are difficult 
things to work through legally and morally and ethically and 
practically. This is the sort of thing you do train for and 
think about. You think about what is going to happen if I have 
to take care of 20 people at once and I don't have enough to do 
it or 100 people or 1,000 people at once, and I don't have 
enough people to do it. I think that we need to consider these 
issues and think through them. This is something we are happy 
to support, support HHS, which was clearly in these sorts of 
situations. The greater community, the greater society has a 
role to play and I think in practical terms were one of these 
things to be carried out.
    Our department, HHS, and many others would be involved in 
some of the decision-making and the communications of this 
because there is also an issue of having the public understand 
what we all are facing and being open and honest with the 
public.
    Dr. Pane. All our work at HHS, basically the raison d'etre, 
if you will, is geared toward helping the health system meet 
surge capacity and deliver the best quality care no matter what 
hits us and no matter how much. Our guidance is really geared 
towards hospitals and states optimizing the use of resources 
whether it is the community, the docs in the community, 
clinics, primary care sites, alternative sites of care to being 
able to call up medical volunteers, share ventilators, work 
together to share resources to take on whatever hits us and 
keep the standard of care high. That said, for standards of 
care, and we did agree with Ms. Bascetta' report that the GAO 
report was excellent. It is an important issue.
    It is also important to note detailed standards of care are 
happening locally. The Federal Government does not set 
standards of care, but we can do guidance and best practices, 
and I think we need to do more in this area. One thing that HHS 
has done is contracted, as was mentioned, with the Institute of 
Medicine, an esteemed group, and they issued or are issuing or 
finalizing some guidance in alternative standards of care. 
There is going to be a second part of that report. I know, as 
was mentioned, the Agency of Healthcare Research and Quality 
was contracted for and they issued a guide. I think some States 
have used that.
    We are also trying to collect lessons-learned or 
innovations that I mentioned earlier in this area. Some States 
are ahead of others in fatality management planning or 
alternative standards and we want to capture those, so a lot of 
activities there. But I just wanted to emphasize our goal is to 
deliver the top notch and best care we can under any scenario 
and expand to do it. Alternative standards of care is one 
aspect of that, and we are going giving it more attention.
    Mr. Carney. Ms. Fitzgerald, please.
    Ms. Fitzgerald. From a State health department perspective, 
we see our goal as taking the Federal guidance as well as some 
of the other best practices that the States have started to 
develop and make sure that our health care partners across the 
State are aware of these materials and that we hold forums to 
have discussions prior to an emergency so that we can better be 
on the same page during the emergency because these discussions 
are tricky and involve a variety of professionals that need to 
come to the table. So in developing this guidance document that 
is almost ready to be released, it will initiate a lot of great 
conversations across the State so that health care 
professionals and emphasis can be more on the same page prior 
to the emergency and, therefore, be better ready to respond and 
take care of the patients during an emergency.
    Mr. Carney. From your perspective, should the altered care 
plan come from the States upward or from the Federal Government 
downward? Should each State have its own standard, should each 
locality have its own standard or should it be----
    Ms. Fitzgerald. Well, I think one of the challenges when 
you talk about standards of care is that in the end is it 
becomes a very individualized patient-physician decision at the 
bed side, and so I think when you are talking about standards 
of care you are really needing to talk about modified health 
care delivery based on certain circumstances, and so I think 
the guidance that the Federal Government and the State 
governments can put out to identify possible scenarios and 
possible responses to the scenarios is the best thing we can do 
to provide support to the individual physician at the bedside.
    Mr. Carney. Ms. Bascetta, please.
    Ms. Bascetta. Thank you. From our perspective, as you have 
heard, once an event occurs there are going to be very 
difficult choices that need to be made. The best example is 
what would have happened in pan flu if it had been much more 
virulent and we had needed to take people off of respirators, 
decide, you know, who was going--decide how has the best chance 
of survival and will get care is essentially what we are 
talking about, something we are not used to in this country. So 
we don't think that it is the Federal Government's 
responsibility to set those standards, but it does play an 
important role in providing guidance. We seen this IOM report, 
which we haven't fully evaluated it but we see it as a very 
important step in providing that general guidance to the 
States, but we do think that there needs to be a heavy local 
component.
    The most important thing is to remember that as fully and 
as transparently we can discuss these issues above-board before 
an event then the greater the potential is that the choices 
that we will be making will be ethically sound, and, more 
important, generally accepted by the public.
    Mr. Carney. Thank you. We will explore that again. Mr. 
Bilirakis.
    Mr. Bilirakis. Thank you, Mr. Chairman. Ms. Fitzgerald, in 
the event of an emergency in surrounding States like New York 
and New Jersey, Pennsylvania might experience an influx of 
patients and evacuees. Are Pennsylvania's hospitals prepared to 
receive these patients if need arises?
    Ms. Fitzgerald. Hospitals have spent the last many years 
considering surge options and developing plans to manage surge. 
I think that hospitals will have an easier time managing surge 
from another area than when the entire State might be affected 
through a pandemic, for example. We know that hospitals are 
extremely busy every day and don't have a lot of immediate 
resources for surge, but I think hospitals have done a lot of 
planning to plan for surge. In addition, we have a lot of 
resources throughout the State that can be brought in to assist 
with the hospital or patients could be dispersed throughout the 
State. So while I think there is always more planning and 
training and exercising that we need to do, I think hospitals 
have done a lot of great work to prepare for a surge.
    Mr. Bilirakis. How does Pennsylvania handle issues 
surrounding the credentialing medical personnel that may wish 
to volunteer during a disaster or terrorist attack? What issues 
might medical professionals from outside the Commonwealth face 
in trying to volunteer in Pennsylvania? Last, what issues may 
medical professionals from Pennsylvania face in trying to 
volunteer in other States?
    Ms. Fitzgerald. Pennsylvania has developed the Statewide 
Emergency Registry for Volunteers in Pennsylvania called 
SERVPA. It is a database that connects directly to our 
Department of Licensure so that we are able to verify medical 
licenses and nursing licenses when people register in our 
system and we are able to verify that as we to deploy a 
volunteer. So we are able to easily verify people who volunteer 
within the State. As far as sending volunteers to other States, 
obviously we can share our credentialed volunteer's information 
with other States if they are deployed to other States.
    As far as allowing volunteers to work in Pennsylvania, that 
is an agreement we would have to have with another State. So I 
think we have done a lot of planning around this issue but I 
think there is additional planning we can do to make sure it 
would be a smooth transition to allow people from other States 
to work in Pennsylvania.
    Mr. Bilirakis. Thank you. I yield back, Mr. Chairman.
    Mr. Carney. Thank you, Mr. Bilirakis. On the crisis 
standards of care issue, Dr. Pane, what is HHS' recommendation 
on the standard? You haven't signed on necessarily to a more 
National element. Do you have a thought on this?
    Dr. Pane. Yeah, I think the whole concept of alternative 
standards of care, crisis standards of care, it is an important 
issue and we are trying to take that on. The States and others 
have raised that, GAO. It is certainly part of what you do in a 
disaster. You need to consider all your options and standards 
of care. Should you be overwhelmed is certainly one of them. So 
to put a little more meat on the bones there and get more 
enlightened guidance, I think both based on the current science 
and also what the consensus is was mentioned, a practitioner--
as you know, in Government, and I feel as a local health 
director, I could only do what the public believed in and 
supported.
    So in order to do that, you really have to get the science 
thing down but you have to get the concepts that are accepted 
by a large majority of people and health professionals, so I 
think that is what the IOM, HHS contracting with them to bring 
together that kind of a group of experts to move that ball down 
the field, and there will be more to say about that, and also 
the AHRQ project. But, again, as was mentioned, this is a local 
issue. Standards of care and the nuances are set. Even 
vaccines, CDC issues a list of priorities but in H1N1 States 
had to make decisions between the lines, and this happens all 
the time. So we rely on our States and local professionals to 
make the hard, tight, close decisions, but certainly from the 
Federal side we can draw experts and come up with guidance and 
some of the principles, things that work that will enable that 
process and make it better.
    Mr. Carney. Ms. Fitzgerald, I had a question in terms of 
just a numbers question. What is the surge capacity for the 
mobile hospitals for the State now, do you know? How many beds 
can we bring to bear if need be?
    Ms. Fitzgerald. Yes. Each of the eight portable hospitals 
has 50 beds that can take care of up to seven patients a day, 
so they can each take of care up to about 350 patients a week, 
and so it brings significant surge capacity that is also mobile 
so that we can move it where I believe we need to in the State. 
In addition, the 19 medical surge trailers also have 50 beds in 
each of the trailers. The difference is the medical surge 
trailers don't come with their house basically, and you would 
set up the medical surge trailers in a fixed facility such as a 
gymnasium.
    Mr. Carney. We had the pleasure this morning of visiting 
Geisinger and looking at sort of the remote care that they--the 
I system--that they have to help remotely care for patients. Do 
you see that coming on-line or do you see any hope for that in 
terms of surge capacity?
    Ms. Fitzgerald. I had seen that system I guess today for 
the first time so I haven't, I apologize, thought a lot about 
that system, but I was----
    Mr. Carney. You can kind of free associate here, if you 
like, from your position.
    Ms. Fitzgerald. I was really impressed with that system and 
I think it looks like there is a lot of opportunity for being 
able to expand the number of patients that can be cared for.
    Mr. Carney. That was my impression as well, but hearing it 
from the professionals would be great. Ms. Bascetta, in your 
estimation from the GAO's perspective, what are the top two or 
three challenges that you see in terms of preparedness and 
surge capacity and that sort of thing, and how do we address 
them?
    Ms. Bascetta. One is related to the decline in the economy 
that we are experiencing. Public health departments have been 
chasing the same kinds of budget cuts that other State 
functions face so that is a matter of funding, and it is all 
dollars. The places that are particularly hidden as situations 
are surveillance and finding clinical access to especially low-
income, low-income people. We have talked a lot about crisis 
standards of care, and we see progress being made in an area. 
We would like to be able to see States take advantage of the 
IOM report and the Federal clearinghouse if and when it is 
actually put on-line to get some things down on paper ahead of 
disasters, and continuing to learn from experiences like 
Katrina and pan flu in particular is a very, I think, fruitful 
area for us to continue pursuing.
    Mr. Carney. Given the scarce resources that you just 
mentioned, where would you focus those scarce resources right 
now to get the most bang for the buck?
    Ms. Bascetta. That is a good question. I think that the 
all-hazard perspective and making sure that there are a lot of 
things where dual use is really important, making sure that 
surveillance isn't compromised, that there is basic public 
health access functions for the low-income populations where 
people with chronic conditions are not compromised so that you 
are faced with a disaster. You have got an ability to do the 
kind of triage that you need in the local area continuing to 
shore up the basic public health functions. I think that is 
important because that is the piece that needs to interact with 
law enforcement and other responders.
    Mr. Bilirakis. Thank you. Dr. Jolly, are the incident 
management assistant teams that Secretary Napolitano spoke of 
assisting the MMRS system and providing effective support at 
the local response, and is HHS supporting the MMRS system with 
supplies from the National strategic stockpile?
    Dr. Jolly. Well, in response, there is a complex group of 
response elements that would all come into play. Incident 
management assistant teams are part of the FEMA response 
framework. We support that. Other departments support that. To 
take Federal leadership into a region and they go on the ground 
in various crises, including one that is on the ground in Haiti 
now to assist with that part of the Federal response, the MMRI 
systems work within the State and the local level and our local 
resources that are designed to build up the response 
immediately before those IMATs can get there. The strategic 
nationals stockpile, should it be needed, is a CDC asset and 
assets from that either medical countermeasure or PPE medical 
equipment, other things that are in the S&S be needed, those 
would quickly be lost and brought into a State and then 
distributed in accordance with State guidelines for how those 
things get distributed. So it is essentially a response web for 
how those things get distributed, so it is essentially a 
response web that all works together, starting at the local 
level at the most basic level of response and building up to 
include the various Federal assets that are there.
    Mr. Bilirakis. Thank you. Dr. Pane, is there a shortage of 
N95 respirator masks in the health care setting, and what is 
driving that shortage, if one exists? Is it cost, product 
capability and/or allocation? Where is the perceived bottleneck 
occurring and is there enough vaccine available to not only 
health care workers but law enforcement in a timely manner to 
ensure that personnel protection if there is personal 
protection if there is any shortage of N95 respirator masks for 
them?--so a concern about the protection, yes.
    Dr. Pane. Congressman, I may need to get back to you on 
some of the details on this. The CDC is really the lead on 
this, but it definitely is an area that was recognized and is 
being looked at by them. On the N95 masks, I know the big issue 
that was discussed, and I think my colleagues were on these 
calls as well, had to do with when do you use N95, who needs it 
and when versus a more simple mask which are readily available. 
I think a supply of ventilator, N95 masks, and regular masks is 
important. The main issue, and I think CDC is working on this, 
I don't know if there was a final conclusion, there was some 
difference between what the OSHA standards were regarding N95 
masks and perhaps the response standards, so the only issue--
there is enough depending on what the criteria is. If the 
criteria move a little, there may be a shortage. So I think the 
CDC--we will have to get back to you on if there is final 
guidance or where they stand in that process but it all came 
down to when is it appropriate clinically to use a regular 
mask. I think it is prolonged periods of intense contact with 
folks who are infected you would use an N95 versus a regular 
mask, so that is the status of that as far as I can tell right 
now.
    Mr. Bilirakis. Thank you, sir. Thank you, Mr. Chairman. I 
yield back.
    Mr. Carney. Thank you. We will close this panel of the 
hearing on this, my last couple of questions. Dr. Pane, since 
funding for hospital preparedness programs, hospital 
preparedness programs is, I think we would all agree, not as 
great as it should be. How concerned are you that States and 
Tribal entities and localities have what they need? Will they 
be able to build and maintain a medical surge capacity? What 
impediments are we facing here? Is there a formula for funding 
you think each hospital should have? Is there some way that we 
can adequately assess where we are in terms of being able to 
address and respond to any kind of need, be it natural or man-
made?
    Dr. Pane. Mr. Chairman, I share your thoughts and concerns 
on that. We know, as I mentioned earlier, the States, the 
incredible stress they are under now with the economics and 
other issues, and we try to be responsive to them. In our 
guidance, we made it a 3-year planning cycle rather than a 1-
year, which was brought up. We made it a July-to-July budget 
cycle, which is no easy matter for HHS, but we did get that 
through to try and make it better and stretch those dollars 
further. It is a formula-based program. Essentially its 
population is how you get your share, and then at the State 
level though they determine the allocation and planning based 
on your needs, what priorities and which hospitals or which 
health facilities get the dollars.
    You can give it to entities besides hospitals, but I think 
historically given the amounts it mostly went to hospitals to 
work on. We thank you and Congress for giving us an extra 
supplement of $90 million this year to put out for H1N1 which 
was a supplement. I know CDC got some extra dollars as well. We 
also did a small grant to many of the States on the health 
volunteer program, the ESAR-VHP program, to kind of move that 
ball along. So you are right though. We need to walk and chew 
gum and have multiple use for these things and get the maximum 
bang out of the buck here, and I think our State is doing a 
great job and we are going to continue--whatever you provide, 
we got a way to spend it and we will try to get the maximum out 
of it to have localities prepared, which is what this is all 
about.
    Mr. Carney. So you are going to tell me how much more you 
actually need then, right?
    Dr. Pane. Write a check and we will spend it. We did a few 
years ago have a partnership program which funded the Hershey--
--
    Mr. Carney. Sure.
    Dr. Pane. You know that, and we welcome your support and we 
appreciate what you have done for us.
    Mr. Carney. Okay. Well, I would like to thank the panel for 
their testimony and for answering the questions we put before 
them. I am almost certain that the subcommittee and perhaps the 
larger committee will have further questions. We will address 
them in a letter to you. Please respond in a timely fashion if 
we do so. This panel stands adjourned. We will reconvene in 15 
minutes. Thank you.
    [Recess.]
    Mr. Carney. The second panel will begin now and I would 
like to welcome the second panel witnesses. Our first witness 
is Dr. John Skiendzielewski. He serves as an emergency room 
physician and Director of the Emergency Medicine Service Line 
for the Geisinger Health System in Danville. He attended St. 
Joseph's College and Temple University School of Medicine. He 
has worked at Geisinger since finishing residency and served as 
residency director before becoming department director. Dr. 
Skiendzielewski served on the ACEP board of directors from 1998 
to 2003. He has also published over 20 articles. He currently 
lives in Danville, Pennsylvania with his wife, Kathleen.
    Our second witness is Dr. Michael N. O'Keefe. Dr. O'Keefe 
was appointed President and CEO of Evangelical Community 
Hospital in September 2004 after serving the hospital 
previously as Executive Vice President and Chief Operating 
Officer, and Vice President of Operations. He holds a Master's 
of Public Administration degree from the American University 
and a Bachelor of Arts degree from St. Lawrence University of 
Camden, New York. Prior to working at Evangelical, Dr. O'Keefe 
served as Vice President for Operations at Newark-Wayne 
Community Hospital in Newark, New York from 1984 to 1991, and 
was the Administrative Assistant for Professional Services and 
Director for Health-Related Services for the Community General 
Hospital of Syracuse, in that position from 1977 to 1984. Dr. 
O'Keefe lives in Lewisburg with his wife, Gail, and they have 
three grown children.
    Our third witness is Mr. Robert A. Kane, Jr. Mr. Kane has 
worked at Susquehanna Health in many capacities since 1974. He 
currently serves as the Vice President of Operations and is 
responsible for the Williamsport Regional Medical Center's 
emergency department, paramedic department, adult and pediatric 
hospital program, the family medicine residency program, and 
all of Susquehanna Health's emergency preparedness programs. 
Bob has been managing many of these programs since 1988. 
Pertinent education experience includes an MBA from Bucknell 
University in 1996, a BS in Business Administration from Upper 
Iowa University in 1984, Liberal Arts studies at Lycoming 
College in 1981, a certification in the health care leadership 
course at the Center for Domestic Preparedness from Aniston, 
Alabama, 2006. We are familiar with all those places.
    Our fourth witness has traveled to Pennsylvania from St. 
Petersburg, Florida at the invitation of our Ranking Member, 
Mr. Bilirakis. At this time, I will give Ranking Member 
Bilirakis the pleasure of introducing his witness.
    Mr. Bilirakis. Thank you, Mr. Chairman. I am pleased to 
introduce Mr. Gary Carnes, President and CEO of All Children's 
Health System in St. Petersburg, Florida. Mr. Carnes joined All 
Children's Hospital in 1997 as its Executive Vice President and 
Chief Operating Officer and has held his current position since 
2002. Prior to his service with All Children's, Mr. Carnes held 
positions at St. Anthony's Health Care and Ramsey Health Care 
Corporation, another excellent institution. Mr. Carnes has a 
Bachelor's of Science in Allied Health Professions and a 
Master's of Business Administration in Finance. Founded in 
1926, All Children's Hospital is the only specialty licensed 
children's hospital on Florida's west coast. In 2007, it was 
named for the fourth consecutive time among the top 25 
children's hospitals in the United States and the best in 
Florida by Child magazine.
    Earlier this month, All Children's moved into its new 
state-of-the-art facility. In addition to enhancing day-to-day 
patient care, this new facility has features that will be 
central during a natural disaster, terrorist act, or other mass 
casualty event, God forbid we have one. For instance, the 
emergency center and the new facility is more then triple the 
size of the emergency room in the old hospital. The central 
energy plant that is part of the new complex is designed to 
keep the hospital fully functioning with air conditioning, and 
of course in central Florida we got to have air conditioning, 
for up to 3 weeks in the event of a disaster or power 
interruption. In addition, the building's helipad was designed 
to accommodate military aircraft which will enhance the 
hospital's ability to receive patients arriving on all types of 
helicopters during an emergency.
    I welcome Mr. Carnes to our subcommittee. I look forward to 
the unique perspective you will bring to this hearing. Thank 
you, Mr. Chairman. I appreciate it.
    Mr. Carney. Thank you, Mr. Bilirakis. If there is no 
objection, I would like to submit for the record written 
testimony that was received from the Hospital and Healthsystem 
Association of Pennsylvania. Hearing no objection, the written 
statement will be entered into the record.
    [The information follows:]
 Statement of The Hospital & Healthsystem Association of Pennsylvania 
              Submitted for the Record by Chairman Carney
                            January 25, 2010
    The Hospital & Healthsystem Association of Pennsylvania (HAP) 
represents and advocates for the more than 252 acute and specialty care 
hospitals and health systems across the Commonwealth of Pennsylvania, 
and the patients they serve. HAP appreciates the opportunity to present 
testimony regarding closing the gap in medical surge capacity in 
Pennsylvania, the Nation's sixth most populous State.
    Pennsylvania's proximity to the Nation's capital and other 
metropolitan areas, such as New York City, make it a vital part of the 
Mid-Atlantic Region. However, these characteristics, combined with 
Pennsylvania's unique geography, also make it vulnerable to natural and 
man-made risk, along with being susceptible to the effects of a larger 
regional incident.
    Currently, health care systems are operating at or near capacity. 
Rural, suburban, and urban areas in the commonwealth each face the 
challenge of little flexibility for absorbing a substantial surge in 
demand for care. Current guidance suggests that a community, including 
hospitals, should be prepared to self-sustain for up to 72 to 96 hours 
before Federal relief resources may arrive.
    Federal money that has been allocated for medical surge has been 
supportive of building medical surge capacity in Pennsylvania, 
especially enhancing event management. Over the past several years, 
hospitals have purchased decontamination units and supplies; radios for 
communication, triage tags, and established limited stockpiles of 
supplies and pharmaceuticals. Overarching emergency plans have been 
developed and exercised. Lessons learned from exercises have provided 
an opportunity to improve emergency plans and staff training. Hospitals 
and health systems have been working on flexible strategies to 
accommodate internal medical surge capacity. While hospitals have 
thought about the flexibility to accommodate medical surge, capacity to 
accommodate surge must continue to be expanded and grown.
    The H1N1 outbreak illustrates how hospitals found the flexibility 
to accommodate a medical surge. Hospitals established alternate 
treatment sites for influenza-like illnesses outside of the emergency 
department. One hospital used an adjacent building to the emergency 
department to direct anyone with influenza-like illness to be screened 
at that location before entering the emergency department. Other 
hospitals established trailers on hospital property to be the sole 
location to screen and treat influenza-like illness. Other hospitals 
established clinics to treat influenza-like illness in other non-
patient care areas in their facility. As they worked to address 
increased outpatient volume because of H1N1, hospitals used supplies 
from their in-house stockpiles. Hospitals relied upon plans that were 
exercised and revised. Staff was familiar with plans that were 
activated due to training and exercises.
    However, hospitals faced challenges during the H1N1 outbreak, 
including supply shortages of N95 respirators and antiviral 
pharmaceuticals. Some hospitals experienced double or more of normal 
emergency department visits due to H1N1, stretching staff and other 
resources as they cared for patients.
    Continued Federal disaster preparedness funding will help hospitals 
to expand medical surge in Pennsylvania. Dedicated funding for medical 
surge capacity planning targeted to the regional level is critical. 
Four key areas to focus expansion of medical surge capacity include 
staff, resources, facilities, and infrastructure:
                                staffing
    In Pennsylvania, there are multiple databases, such as SERVPA, to 
access additional staff in a medical surge scenario. HAP suggests it is 
appropriate to move forward from the databases to organizing and 
training individuals listed in the databases for possible medical surge 
scenarios.
                               resources
    As the H1N1 outbreak grew, hospitals used their limited stockpile 
of N95 respirators and antiviral pharmaceuticals. Hospitals shared the 
challenges and concerns about the inability to receive ordered 
materials due to a 6- to 8-month backorder. HAP suggests that public 
policymakers examine avenues to provide a robust supply chain of needed 
resources to health care facilities in the event of a peak demand that 
could occur in an outbreak, such as H1N1, or in a major disaster.
                               facilities
    Hospitals have examined ways to create surge capacity within their 
own facilities and campuses. Hospitals also have worked with community 
partners to determine where alternate care sites could be located. HAP 
suggests that the multi-disciplined community planning efforts for 
medical surge continue.
                             infrastructure
    When hospitals surge into non-traditional patient care spaces, such 
as a lobby, it is necessary to determine how to support the needs of 
medical care that may occur there such as oxygen, suction, and cardiac 
monitors. The same holds true if an alternate care site is opened in a 
school or library. How is medical care supported in that venue? HAP 
suggests that efforts should continue regarding how to support 
alternate care sites on hospital campuses, as well as off-campus sites 
such as a library or school.
    HAP and its member hospitals and health systems appreciate the 
opportunity to submit testimony and to provide the Pennsylvania 
hospital and health system community's perspective on medical surge. 
HAP supports continued Federal funding for disaster preparedness to 
enable hospitals and health systems to respond to health care needs 
that can arise during major public health crises, natural disasters, or 
other disaster events.
    HAP looks forward to future discussions on this important issue.

    Mr. Carney. I would like to thank each of you witnesses for 
your testimony. I will remind you that you will have 5 minutes 
to sum up beginning with Dr. Skiendzielewski.

STATEMENT OF JOHN J. SKIENDZIELEWSKI, M.D., DIRECTOR, EMERGENCY 
    MEDICINE SERVICES, GEISINGER MEDICAL CENTER, DANVILLE, 
                          PENNSYLVANIA

    Dr. Skiendzielewski. Thank you. Good afternoon, Mr. 
Chairman, and Mr. Bilirakis. I would first like to discuss 
Geisinger's emergency preparedness efforts, and then outline 
our efforts in conjunction with our community partners, and 
conclude by offering several observations and recommendations. 
Geisinger has a long and rich history of leadership and 
disaster planning that dates back at least 30 years. At that 
time we developed a five-county disaster plan and exercises 
were conducted with a significant number of community partners. 
Within a six-hospital consortium there were annual drills of 
inter-hospital disasters. Since 1998, we have participated in 
the east central Pennsylvania regional task force.
    These counties worked to define groupings by their natural 
mutual aid alliances. Each task force consists of 
representatives from emergency medical services, law 
enforcement, emergency management agencies, fire/rescue, and 
hazardous material response teams. Our emergency management 
programs are focused on addressing a wide variety of potential 
disasters or incidents that may affect the community. These 
include natural disasters, man-made disasters, and 
technological events. We conduct an annual review of our hazard 
vulnerability by considering incident probability, impact on a 
facility, and services at our current preparedness level.
    We have adopted a variety of response templates appropriate 
to the disaster events that we might face. We drill and 
exercise our response to many of these situations each year. In 
addition to mass casualty trauma events a few other examples 
include handling radiologically-contaminated injured patients, 
decontamination of chemically-contaminated patients, as well as 
floods, blizzards, and other internal and external disasters. 
We have worked with both the State and Federal Government in 
relation to the strategic National stockpile program. One of 
the Pennsylvania Department of Health Medical Surge Equipment 
Caches portable trailers is based at the Danville Ambulance 
Service.
    We have developed a detailed system-wide pandemic response 
plan. This plan remains in effect today at this time due to the 
H1N1 pandemic. We continue to focus on increasing our surge 
capacity through development of alternate care-site plans. We 
continue to serve as a non-metropolitan resource for patients 
from terrorist acts that may occur. With five medical 
helicopters, we can provide a redistribution function of 
critical patients from other areas to our tertiary/quaternary 
care centers. We have developed and maintained effective 
relationships with our community partners, including local 
fire, police, EMS, county emergency management, local emergency 
planning committees, hospital support zone group, regional task 
forces, and others.
    With regard to emergency preparedness, the region 
demonstrates a high level of collaboration rather than 
competition. We have participated together with community 
partners in joint planning, training, and exercise events. 
Based on our emergency preparedness experience, I would like to 
offer the committee several observations and recommendations to 
consider to help strengthen hospital disaster planning and 
response. No. 1, rural disaster planning and execution is 
significantly different from urban disaster planning and 
execution and poses significant and unique challenges. Our EMS 
services are dependent to a great extent on volunteers making 
attendance at planning meetings and participation in drills and 
exercises very problematic. Our recommendation: Make additional 
planning and coordination funds available to address the 
specific emergency preparedness challenges faced by rural 
health providers.
    No. 2, the current medical surge equipment caches include 
many items with finite shelf-life. Future emergency 
preparedness funding may be exhausted simply to keep supply and 
response equipment current. Our recommendation: Provide 
dedicated supplemental funding to account for aging equipment 
stockpiles that will need to be replaced. No. 3, the current 
emergency preparedness grant funding formula that allocates 
funding to hospital providers does not account for the size of 
the facility's emergency department or if it has a trauma 
center designation. Our recommendation: Amend the current 
funding distribution formula to account for the size of the 
hospital ED and for trauma center designations to appropriately 
direct additional disaster funding to larger and more 
specialized facilities.
    No. 4, costly security measures and upgrades needed to deal 
with disaster surge in at-risk locations have not been allowed 
as approved grant expenditures for several years. 
Recommendation: Authorize security and infrastructure 
protection as acceptable expenditures under future emergency 
preparedness grants. No. 5, we are in the process of developing 
and implementing an electronic intensive care unit or e-ICU 
program. As the e-ICU program grows and reaches out to regional 
hospitals, it will become a valuable asset in confronting any 
mass casualty disaster.
    Our recommendation: Provide seed funding for e-ICU programs 
to enhance image transfer capabilities, including connectivity 
to regional hospitals to expand surge capacity. We appreciate 
the support and direction that has allowed us to enhance our 
disaster planning efforts over the recent years. Thank you, and 
I will be happy to answer any questions you may have.
    [The statement of Dr. Skiendzielewski follows:]
             Prepared Statement of John J. Skiendzielewski
                            January 25, 2010
    Good afternoon Congressman Carney and Members of the committee. 
Thank you for the opportunity to comment on Geisinger Medical Center's 
emergency preparedness efforts. My name is John Skiendzielewski and I 
am an emergency medicine physician and director of the Emergency 
Medicine Service Line for the Geisinger Health System in Danville. I am 
joined today by Dr. Al Bothe, Geisinger Medical Center's executive VP 
and chief medical officer.
    Geisinger Health System is a fully-integrated health care delivery 
system that includes a multidisciplinary physician group practice with 
system-wide aligned goals, successful clinical programs, a robust 
information technology platform, and an insurance product (Geisinger 
Health Plan). Geisinger's service area covers a 41-county region in 
central and northeastern Pennsylvania with a population of 
approximately 2.6 million. Research, education, and community service 
are also integral parts of Geisinger's mission. Geisinger Medical 
Center in Danville is the system's flagship hospital. Geisinger Medical 
Center is the region's tertiary/quaternary care hospital. It is staffed 
by more than 350 specialists and subspecialists and is the education 
site for residents and fellows in 28 specialties. The medical center is 
home to a Level I trauma center with a pediatric designation, centers 
for heart, cancer, and brain diseases, stroke and transplant programs 
and the Janet Weis Children's Hospital, Weis Research Center, and the 
Henry Hood Center for Health Research.
    I would first like to discuss Geisinger's emergency preparedness 
efforts and then outline our efforts in conjunction with our community 
partners and conclude by offering several observations and 
recommendations.
    Geisinger has a long and rich history of leadership in disaster 
planning that dates back at least 30 years. At that time, a regional 5-
county disaster plan was developed, and exercises were conducted with a 
significant number of community partners. Within a 6-hospital 
consortium, there were annual drills of inter-hospital disasters, 
including triage exercises and inter-hospital communications.
    Since 1998, we have participated in the East Central PA Regional 
Task Force (ECTF) that was formed in response to the threat of the use 
of weapons of mass destruction. This is one of nine regional task 
forces in Pennsylvania, originally known as Regional Counter-Terrorism 
Task Forces. The counties worked to define groupings by their natural 
mutual aid alliances. Each task force consists of representatives from 
emergency medical services, law enforcement, emergency management 
agencies, fire/rescue, and hazardous material response teams. This is a 
partnership with various State and Federal officials having regional 
responsibilities from such agencies as the Federal Bureau of 
Investigation, Bureau of Alcohol, Tobacco, and Firearms, Pennsylvania 
State Police, National Guard, Environmental Protection, and others.
    Since 9/11/2001, we have adopted a command and response system 
known as the Hospital Incident Command System. This system is modeled 
after and integrated with the National Incident Management Framework. 
Funded through Federal emergency funds, numerous employees have 
received disaster training as well as on response procedures for a wide 
variety of disaster types.
    Our emergency management programs are focused on addressing a wide 
variety of potential disasters or incidents that may affect the medical 
community. These include natural disasters, man-made disasters, and 
technological events. We conduct an annual review of our hazard 
vulnerability by considering incident probability, impact on the 
facility and services, and the current preparedness level. We develop 
and modify our emergency response plans based upon risk determination 
that is ranked using this methodology. We have adopted a variety of 
response templates appropriate to the disaster events we might face. We 
drill and exercise our response to many of these situations each year. 
In addition to mass casualty/trauma events, a few other examples 
include handling radiologically-contaminated injured patients, 
decontamination of chemically-contaminated patients, as well as floods, 
blizzards, and other internal and external disasters.
    A number of emergency communication enhancement projects have been 
completed. These include the establishment of the State-wide radio 
system linking hospitals and emergency response agencies and the 
establishment of the Facility Resource Emergency Database or FRED. 
These tools provide additional valuable key links to enhance 
communication and coordination activities during a disaster.
    We have worked with both the State and Federal government in 
relation to the strategic National stockpile program. This program is 
beneficial when disasters generate an increased need for supplies and 
medications beyond what may be available through normal vendor 
channels. One of the Pennsylvania Department of Health MSEC (Medical 
Surge Equipment Cache) portable trailers is based at Danville's 
Ambulance Service's station. In addition, we provide medical direction 
to Danville Ambulance and other EMS units (including ambulances, 
tactical police medical units, and police department defibrillator 
programs).
    We have developed a detailed system-wide pandemic response plan. 
This plan remains in effect at this time due to the H1N1 pandemic. This 
information is also shared with surrounding hospitals and higher 
education institutions.
    We continue to focus on increasing our surge capacity through 
development of alternate care site plans. Also, we have focused on 
increasing our self-sustainability during a disaster.
    We continue to serve as a non-metropolitan resource for patients 
from terrorist acts that may occur near us. With 5 medical helicopters, 
we can provide a redistribution function of critical patients from 
other areas to our tertiary/quaternary care centers.
    We have developed and maintained effective relationships with our 
community partners, including local Fire, Police, EMS, County Emergency 
Management, Local Emergency Planning Committees, Hospital Support Zone 
Group, Regional Task Forces, and others. With regard to emergency 
preparedness, the region demonstrates a high level of collaboration 
rather than competition. We have participated together with community 
partners in joint planning, training, and exercise events. We have 
established memorandums of understanding or MOU's with the regional 
task forces. These documents provide guidelines for the sharing of 
equipment and staff in disaster situations. Within our task force, 16 
hospitals have signed the MOU.
    We have developed local hospital support zones. For example, the 
local zone that includes Danville involves 8 hospitals, emergency 
management agencies, visiting nurse agencies, the American Red Cross 
and others. This is a sub-set of the 7-county task force. The support 
zone serves as a valuable forum for sharing information, planning, and 
support activity. This group generally meets 4 times per year.
    Based on our emergency preparedness experience I would like to 
offer the committee several observations and recommendations to 
consider to help strengthen hospital disaster planning and response.
    (1) Rural disaster planning and execution is significantly 
        different from urban disaster planning and execution and poses 
        significant and unique challenges. For the most part rural 
        areas in the Commonwealth do not have large county-wide police, 
        fire, or EMS services. They are also dependent to a greater 
        extent on volunteers to provide a wide range of response 
        services making attendance at planning meetings and 
        participation in drills and exercises problematical. Most small 
        to mid-size rural hospitals do not have staff dedicated to 
        emergency management nor do they have specific emergency 
        management budgets.
    Recommendation.--Make additional planning and coordination funds 
        available to address the specific emergency preparedness 
        challenges faced by rural health providers.
    (2) The current medical surge equipment caches include items with 
        finite shelf life. Items such as protective gear, medical 
        supplies and battery-powered sources have expiration dates that 
        will increasingly require replacement of aging stockpiles. 
        Future emergency preparedness funding make be exhausted simply 
        to keep supply and response equipment current.
    Recommendation.--Provide dedicated supplemental funding to account 
        for aging equipment stockpiles that will need to be replaced.
    (3) The current emergency preparedness grant funding formula that 
        allocates funding to hospital providers does not account for 
        the size of the facility's emergency department or if it has a 
        trauma center designation. This ``one-size-fits-all'' approach 
        does not adequately direct emergency preparedness funding to 
        larger facilities that would be expected to handle a larger 
        proportion of disaster cases.
    Recommendation.--Amend the current funding distribution formula to 
        account for the size of the hospital ED and for trauma center 
        designations to appropriately direct additional disaster 
        funding to larger facilities.
    (4) Security measures and upgrades needed to deal with disaster 
        surges in at-risk locations including access controls, 
        surveillance cameras, biometric ID systems and related 
        equipment are costly but have not been allowed as approved 
        grant expenditures for several years.
    Recommendation.--Authorize security and infrastructure protection 
        as acceptable expenditures under future emergency preparedness 
        grants.
    (5) One critical shortage in our region is the lack of specialized 
        hospital facilities to care for burn patients. Currently, 
        Geisinger and other hospital emergency departments are 
        initially treating and stabilizing burn patients in preparation 
        of transfers to recognized burn centers out of the region. We 
        are in the process of developing and implementing an electronic 
        intensive care unit (``e-ICU'') program to link by telemedicine 
        to the burn unit at Lehigh Valley Hospital. As the e-ICU 
        program grows and reaches out to regional hospitals it will 
        become a valuable asset in confronting any mass casualty 
        disaster.
    Recommendation.--Provide evaluation and planning resources to 
        consider the status of burn patients within the region. Provide 
        seed funding for e-ICU programs to enhance image transfer 
        capabilities, including connectivity to regional hospitals to 
        expand surge capacity.
    We appreciate the support and direction that has allowed us to 
enhance our disaster planning efforts over the recent years. We hope 
that our input here today helps in crafting future response 
capabilities to meet and mitigate the potential hazards and disasters 
that we may face in the future. Thank you. Dr. Bothe and I would be 
happy to answer any questions you may have.

    Mr. Carney. Thank you. Dr. O'Keefe for 5 minutes, please.

STATEMENT OF MICHAEL N. O'KEEFE, PRESIDENT AND CHIEF EXECUTIVE 
      OFFICER, EVANGELICAL COMMUNITY HOSPITAL, LEWISBURG, 
                          PENNSYLVANIA

    Mr. O'Keefe. Good afternoon. Thank you for your invitation 
to testify today. If I may, let the record show Dr. O'Keefe was 
my father. I am Michael O'Keefe. I serve as the Chief Executive 
Officer of Evangelical Community Hospital in Lewisburg, 
Pennsylvania in Union County. First, I want the Subcommittee on 
Homeland Security and the State and Federal taxpayers to be 
assured that the resources that have been allocated for 
preparedness especially since 9/11 have not been wasted. Since 
that time, there has been much attention paid and advances made 
in the application of technology, surge capacity, security, 
communication, collaboration between and among State, regional, 
and local agencies and organizations.
    Pre-9/11 conditions. The inception of the Regional Counter 
Terrorism Task Forces actually began in 1999. Through funding 
from PEMA, the nine regional State-wide groups began to conduct 
meetings and explore ways to coordinate and acquire equipment 
and supplies that would have interoperability within the 
counties. In the north central region hospitals and other 
agencies were not included in the early stages. PEMA monies 
were primarily used to fund meetings for the county emergency 
management coordinators, not to purchase supplies or expand 
outreach to other agencies.
    Prior to 9/11 Evangelical Community Hospital had little 
focus on terrorism. The concept of preparing for a chemical, 
biological, radiological, or nuclear explosive or CBRNE event 
was extremely remote. The hospital, relatively speaking, had 
not personal protective equipment for such an event. There was 
no facility, fixed or portable, for mass decontamination nor 
were there any plans in place or exercises done. It is probably 
safe to assume that most rural hospitals were in similar 
situations. In addition, the means for mass communications were 
poor. During inter-hospital disaster drills the priority 
complaint was always lack of communication. The category that 
was rated the most important, yet rated the lowest. In those 
pre-9/11 drills the mass casualty events were almost always 
some type of wreckage and occasionally a small amount of 
hazardous material was included. Exercising for chemical, 
biological, radiological, nuclear explosive was never even 
considered.
    Post-9/11. After 9/11 the regional task force realized the 
need to include more agencies and give them a more prominent 
role. Committees were formed around law enforcement, fire, 
search and rescue, hazardous materials, hospitals and pre-
hospital services, training, and equipment. Each committee 
appointed a chair that reported to an executive board. After 
the creation of the Department of Homeland Security, funding 
for the regional counterterrorism task force came from the 
Federal Government and no longer from the State agency, even 
though funds were still distributed through PEMA. This Federal 
funding allows a large amount of dollars to come into the 
individual regions.
    A small amount is used for administration and the remainder 
is dedicated to the purchase of equipment and supplies for each 
of the previously-mentioned committees. The equipment purchased 
includes such items as decontamination trailers, mass casualty 
trailers, hazardous materials trailers, and prime movers. Just 
recently oxygen generators were purchased for each mass 
casualty trailer. There is a state-of-the-art mobile Incident 
Command Post for the region. There is a mass fatality trailer 
and high-tech hospital monitoring detection equipment.
    Supplies have been purchased that meet specific needs of 
each committee. In addition to supplies, personal protection 
equipment have been provided to outfit the many region wide 
responders who may be dispatched. Training is the second pillar 
necessary for a reliable response. In the years just after 9/11 
it was evident that materials for response were greatly lacking 
and most of our funding was applied to those needs. Training 
was not the main concern. However, in the past 2 years North 
Central Regional Task Force has devoted as substantial amount 
of their budget to supporting training. Region-wide drills can 
be extremely costly. Nonetheless, consultants were hired to 
develop and manage major exercises. These included two 
Strategic National Stockpile drills, and a mass casualty drill 
has been contracted for the spring. This has all resulted from 
the focus of the Department of Homeland Security since 9/11. 
Preparedness has indeed been enhanced.
    For hospitals, after the creation of the Department of 
Homeland Security, funding streams were made available to other 
agencies in addition to the equipment and supplies that were 
available through the regional task forces. The Pennsylvania 
Department of Health received Federal monies that are 
distributed to each of the State's hospitals. Previously known 
as the HRSA Grant, the grant is now known as the Hospital 
Preparedness Program or HPP. Since its inception in 2003 
Evangelical Community Hospital has purchased level B and level 
C personal protective equipment. There is enough level C 
equipment to suit 40 Emergency Department staff for response to 
a CBRNE event. Evangelical Hospital now has six level III 
hazardous materials technicians certified through the HPP 
grants and enough level B personal protective equipment to 
outfit all of them. There are additional level C hazardous 
materials techs working as paramedics but most of them were 
trained prior to 
9/11.
    Funding has also enabled Evangelical Community Hospital to 
build state-or-the-art fixed decontamination facility. It has a 
dedicated HVAC system that extends to an isolation room in the 
Emergency Department. This will protect the hospital from 
secondary contamination. It includes a holding tank to capture 
possible contaminated water and other products that will drain 
during the decontamination process. As stated, Evangelical 
Hospital now had a certified team to manage decontamination 
operations. Decontamination surge capacity can also be 
increased by mutual aid with a local fire department, the 
county EMA, and the Bureau of Prisons in Lewisburg. This 
provides additional certified manpower along with a nine-
station portable contamination system.
    Prior to 9/11 Evangelical Hospital had no pharmaceutical 
stockpile in the event of a pandemic. Through HPP funds the 
hospital pharmacy now maintains a cache large enough to support 
the hospital's staff and their immediate families. Once again, 
this contributes to our surge capacity by enabling more staff 
to respond. A large cache of antibiotics is also on hand to 
protect staff in the event of a bio-terrorism attack. A mandate 
from the Department of Health requires recipients of the HPP 
Grant to have surge capacity of 20 percent of their census. 
With 133 licensed beds Evangelical Hospital exceeds that goal 
with 27 beds available. The hospital has purchased enough beds 
and cots for mass care, as well as supplies designed to 
supplement a surge. We have also designed plans to surge up to 
170 casualties above our census.
    Mr. Carney. Mr. O'Keefe, if you could wrap it up.
    Mr. O'Keefe. Thank you.
    [The statement of Mr. O'Keefe follows:]
                Prepared Statement of Michael N. O'Keefe
                            January 25, 2010
    Members of the U.S. House of Representatives Committee on Homeland 
Security: Thank you for your invitation to testify. My name is Michael 
O'Keefe and I serve as CEO at Evangelical Community Hospital in 
Lewisburg, PA, Union County.
    I understood our charge today is to discuss the steps that area 
hospitals have taken to prepare in the event of either a natural 
disaster or an act of terrorism. Specifically, are local hospitals 
ready? What challenges exist regarding our current medical and surgical 
capacity? And, can we identify ways to improve coordination among 
affected organizations?
    First, I want the subcommittee on Homeland Security and the State 
and Federal taxpayers to be assured that the resources that have been 
allocated for preparedness, especially since 9/11, have not been 
wasted. Since that time, there has been much attention paid and 
advances made in the application of technology, surge capacity, 
security, communications, and collaboration between and among State, 
regional, and local agencies and organizations.
                         i. pre-9/11 conditions
Regional Counter Terrorism Task Forces
    The inception of the Regional Counter Terrorism Task Forces 
actually began in 1999. Through funding from PEMA, the nine regional 
State-wide groups began to conduct meetings and explore ways to 
coordinate and acquire equipment and supplies that would have 
interoperability within the counties. In the North Central region 
hospitals and other agencies were not included in the early stages. 
PEMA monies were primarily used to fund meetings for the county 
emergency management coordinators, not to purchase supplies or expand 
outreach to other agencies.
Hospitals
    Prior to 9/11 Evangelical Community Hospital had little focus on 
terrorism. The concept of preparing for a chemical, biological, 
radiological, nuclear explosive (CBRNE) event was extremely remote. The 
hospital, relatively speaking, had no personal protective equipment 
(PPE) for such an event. There was no facility, fixed or portable, for 
mass decontamination nor were any plans in place or exercises done. It 
is probably safe to assume that most rural hospital were in similar 
situations.
    In addition, the means for mass communication were poor. During 
inter-hospital disaster drills the priority complaint was always lack 
of communication. The category that was rated the most important, yet 
rated the lowest. In those pre-9/11 drills the mass casualty event was 
always some type of wreckage and occasionally a small amount of 
hazardous materials was included. Exercising for chemical, biological, 
radiological, nuclear explosive (CBRNE) was never considered.
                              ii.post-9/11
Expansion of the North Central Counter Terrorism Task Force
    After 9/11 the regional task force realized the need to include 
more agencies and to give them a more prominent role. Committees were 
formed around law enforcement, fire, search and rescue, hazardous 
materials, hospitals and pre-hospital services, training, and 
equipment. Each committee appointed a chair that reported to an 
executive board.
    After the creation of the Department of Homeland Security, funding 
for the regional counterterrorism taskforce came from the Federal 
Government and no longer from the State agency, even though funds are 
still distributed through PEMA. This Federal funding allows a large 
amount of dollars to come into the individual regions. A small amount 
is used for administration and the remainder is dedicated to the 
purchase of equipment and supplies for each of the previously mentioned 
committees. This can be a complicated process.
    Equipment purchased includes such items as decontamination 
trailers, mass casualty trailers, hazardous materials trailers, prime 
movers. Just recently oxygen generators were purchased for each mass 
casualty trailer. There is a state-of-the-art mobile Incident Command 
Post for the region. There is a mass fatality trailer and high-tech 
hospital monitoring and detection equipment.
    Supplies have been purchased that meet the specific need of each 
committee. In addition to supplies, personal protection equipment (PPE) 
has been provided to outfit the many region-wide responders who may be 
dispatched.
    Training is the second pillar necessary for a reliable response. In 
the years just after 9/11 it was evident that materials for response 
were greatly lacking and most of the funding was applied to those 
needs. Training was not the main concern. However, in the past 2 years 
North Central Regional Task Force has devoted a substantial amount of 
their budget to supporting training. Region-wide drills can be 
extremely costly. Nonetheless, consultants were hired to develop and 
manage major exercises. These included two Strategic National Stockpile 
drills. A mass casualty drill has been contracted for the spring.
    This has all resulted from the focus of the Department of Homeland 
Security since 9/11. Preparedness has indeed been enhanced.
Hospitals
    After the creation of the Department of Homeland Security, funding 
streams were made available to other agencies in addition to the 
equipment and supplies that were available through the regional task 
forces. The PA Department of Health receives Federal monies that are 
distributed to each of the State's hospitals. Previously known as the 
HRSA Grant, the grant is now known as the Hospital Preparedness Program 
or HPP. Since its inception in 2003 Evangelical Community Hospital has 
purchased ``level B'' and ``level C'' personal protective equipment 
(PPE). There is enough ``level C'' to suit 40 Emergency Department 
staff for response to a CBRNE event. Evangelical Community Hospital now 
has 6 level III hazardous materials technicians certified through the 
HPP grants and enough ``level B'' PPE to outfit all of them. There are 
additional level C hazardous materials techs working as paramedics but 
most of them were pre-9/11.
    Funding has also enabled Evangelical Community Hospital to build a 
state-of-the-art fixed decontamination facility. It has a dedicated 
HVAC system that extends to an isolation room in the Emergency 
Department. This will protect the Hospital from secondary 
contamination. It includes a holding tank to capture possible 
contaminated water and product that will drain during the 
decontamination process. As stated, Evangelical Community Hospital now 
has a certified team to manage decontamination operations. 
Decontamination surge capacity can also be increased by mutual aid with 
the local fire department, the county EMA, and the Bureau of Prisons at 
Lewisburg. That provides additional certified manpower along with a 9-
station portable decontamination system.
    Prior to 9/11 Evangelical Community Hospital had no pharmaceutical 
stockpile in the event of a pandemic. Through HPP funds the Hospital 
pharmacy now maintains a cache large enough to support the hospital's 
staff and their immediate families. Once again, this contributes to our 
surge capabilities by enabling more staff to respond. A large cache of 
antibiotic is also on hand to protect staff in the event of bio-
terrorism attack.
    A mandate from the Pennsylvania Department of Health requires 
recipients of the HPP Grant to have surge capacity for 20% of their 
census. With 133 licensed beds, Evangelical Community Hospital exceeds 
that goal with 27 beds available. The hospital has purchased enough 
beds and cots for mass care, as well as supplies designed to supplement 
a surge. We have also designed plans to surge up to 170 casualties 
above census.
    One percent of HPP funds are required to be spent on training and 
exercises. This year's grant funding provides $450.00 for training. 
Evangelical Community Hospital far exceeds the $450 allocated for 
training when executing just one drill. Our hazardous materials drill 
held annually during the Little League World Series involves 
Evangelical Community Hospital staff and coordinates with nine other 
agencies including the Red Cross, PEMA, Lewisburg Board of Prisons, 
Union County EMA, Bucknell University, local Fire Departments and local 
businesses. This type of coordination and outreach by a small rural 
hospital was never even considered prior to 9/11.
    Other areas that have vastly improved since 2001 are communication 
and technology. As previously stated, communication is always the most 
critical yet poorest performing function of disaster preparedness. 
Since 9/11 the hospital has acquired the 800 MHz radio along with 
``biokey''. That system is located in the hospital's relatively new 
command center. Additional med radios have been purchased to aid pre-
hospital services in a surge response. At no expense to the hospital. 
Evangelical Community Hospital, along with all PA hospitals, now 
subscribe to technological communication systems such as Realtime 
Outbreak Disease Surveillance (RODS), Facility Resource Electronic Data 
(FRED), Infection Surveillance (PA Neiss), and mass reporting (PA Han). 
Hospitals have also acquired a Telephone Priority Service (TPS).
                      iii. where do we stand today
Response Reliability
    Since 9/11 hospitals have been provided an opportunity to obtain a 
large inventory of supplies and equipment. Hospitals in the NCTF have 
been given the privilege of training and exercising with some of this 
inventory.
    However, a critical concern is response reliability. Real-time 
response in disasters such as Katrina have shown that 50% to 80% of 
responders and health care workers will not report to work if there is 
a perceived threat to their immediate families. Responder support must 
not be assumed or taken for granted.
    For example, when Evangelical Community Hospital sets up a 9-
station decontamination system we are prepared to handle approximately 
100 casualties in an hour. But there are never enough responders to 
work all nine stations. Our decontamination rate is cut dramatically. 
Would this occur in a real CBRNE event? It is a difficult question to 
answer. Without enough responders all the equipment, supplies, and 
technology go unused. Careful planning breaks down and a course for 
failure begins to spiral.
    There is no easy solution. Response reliability stands as the most 
critical yet most questionable unmet need. Hospitals are much better 
prepared in the categories of supplies, equipment, pharmacy caches, 
communications, etc. If there is a topic of concern that Pennsylvania 
needs to focus upon today, it is finding a solution to response 
reliability.
    In closing, on behalf of Evangelical Community Hospital and our 
Director of Environmental Safety and Security, I am confident that the 
Hospital is committed to disaster preparedness, as well as execution 
should disaster or terrorism strike. We remain steadfast in our 
partnerships and collaborations with State, county, and township 
officials, as well as with our membership in the North Central and East 
Central Task Forces.

    Mr. Carney. Mr. Kane, please, for 5 minutes.

STATEMENT OF ROBERT A. KANE, JR., VICE PRESIDENT OF OPERATIONS, 
         SUSQUEHANNA HEALTH, WILLIAMSPORT, PENNSYLVANIA

    Mr. Kane. I would like to thank Chairman Carney and 
committee Members for the opportunity to provide this 
testimony. This topic is at the forefront of our emergency 
preparedness efforts at Susquehanna Health. I am representing 
Susquehanna Health in Williamsport, which is made up of 
Williamsport Hospital, Divine Providence Hospital and our 
Critical Care Hospital, Muncy Valley. Our emergency 
preparedness planning has a long history of understanding the 
serious consequences of disasters being at the forefront of 
disaster preparation. In 1989 we opened the region's first 
hazardous materials decontamination center and it had been in a 
continual state of readiness since. Hurricane Gustav hit 
Louisiana in September, 2008 and Susquehanna Health sent 
personnel to aid in hospital evacuations the days before and 
after the storm hit.
    Our Prehospital Medical Director and emergency room 
physician, Dr. Frailey, who is with me here today, provided 
medical direction for our team. Dr. Frailey is one of our 
regional experts with the following experience: 25 years as a 
naval flight surgeon and primary responsibilities to preplan 
for mass casualty incidents, a medical specialist with 
Pennsylvania Task Force One, the regional medical director in 
Lycoming, Tioga, and Sullivan County, and instructs advanced 
life support, international trauma life support, PEMA blast 
injuries, forensics, and crush injury classes and many others.
    In 2009, the Department of Health purchased portable 
hospitals to assist regions in their readiness. We were the 
first in the State to set up and use the portable hospitals to 
prepare for the biggest threat to our region in regards to mass 
casualty, the Little League World Series. Every August, 
Williamsport is in the international spotlight which carries a 
heavy responsibility for our emergency preparedness team to 
accurately forecast and to take the necessary steps to mitigate 
potential man-made or natural disasters. Little League World 
Series more than doubles the population of Williamsport and a 
mass casualty incident is a very real danger that we must 
consider.
    We are here today to outline several key areas that would 
be relevant to your House subcommittee. In many ways, 
Susquehanna Health is prepared to deal with a mass casualty 
incident that happens in our community. Annually, we meet with 
our community partners to identify external vulnerabilities and 
update our emergency operations plan to mitigate these threats. 
Our surge capacity is assessed and systems including pre-
defined locations throughout our three hospitals. Full-scale 
exercises and drills identify our areas for improvement and 
practices. ASPR grant funding helps to mitigate our identified 
needs regarding supplies and equipment. Our planning efforts 
also identify our own internal vulnerabilities.
    Our two emergency departments serve over 60,000 patients a 
year with 43 treatment rooms. Susquehanna Health has started a 
major construction project that will nearly double our 
emergency department treatment capability. Our geographic 
location as a regional population center in the heart of a 
large rural tract implies that we will only be able to depend 
on ourselves to service our population during the initial 
stages of a mass casualty incident. Lycoming County contains 
over 1,200 square miles of territory. Our closest trauma center 
is 45 minutes away by ground. During a mass casualty, we, and 
many other rural facilities will be challenged to maintain 
nurse-to-patient ratios, particularly during a sustained 
incident such as a pandemic.
    In July, 2009, Pennsylvania initiated a ban on mandatory 
overtime. While this is lauded as a positive step forward in 
protecting health care workers and patients, its wording places 
burdens on emergency preparedness. In response to the many 
factors effecting health care organizations nationally, 
hospitals are becoming leaner in staffing, thereby reducing any 
depth for initial and sustained mass casualty operations. Any 
expectation of rural hospitals to staff alternate care sites 
during an event is unrealistic and would further deplete our 
nurse-to-patient ratios and jeopardize patients and staff. Many 
hospitals, Susquehanna Health included, use a just-in-time 
supply inventory system due to limited storage space and as a 
cost savings measure. This limits us further during a sustained 
mass casualty incident.
    In general, open space to expand services into is limited 
throughout our hospitals. Specialty centers within hospitals 
have their own unique regulations that further limit our 
available spaces. Severe weather and mountainous terrain are 
identified as hazards and can also be contributing factors 
delaying aid to our region in a disaster. Our finite community 
resources force us to plan on little to no law enforcement or 
security available during a mass casualty incident. Lack of 
immunity from prosecution to physicians and other health care 
providers may further limit our response to a disaster for fear 
of prosecution.
    This statement also holds true in regards to our rural 
hospitals receiving casualties from a disaster in a large 
population center. If a mass casualty event happened in a large 
population center and we were asked to receive patients from 
it, we would have time to prepare ourselves and to set up our 
surge beds, create real-time staffing plans, and work with our 
community providers.
    Mr. Carney. Mr. Kane, thank you. You are at 6 minutes now.
    Mr. Kane. Okay.
    [The statement of Mr. Kane follows:]
               Prepared Statement of Robert A. Kane, Jr.
                            January 25, 2010
    I would like to thank Chairman Carney and committee Members for the 
opportunity to provide this testimony regarding the medical community 
and medical surge capacity. This topic is at the forefront of our 
emergency preparedness efforts at Susquehanna Health. I am representing 
Susquehanna Health in Williamsport which is made up of Williamsport 
Hospital, Divine Providence Hospital, and our Critical Access Hospital, 
Muncy Valley. Our emergency preparedness planning has a long history of 
understanding the serious consequences of disasters and being at the 
forefront of disaster preparation. In 1989 we opened the region's first 
hazardous materials decon center and it has been in continual state of 
readiness since. Hurricane Gustav hit Louisiana in September, 2008 and 
Susquehanna Health sent personnel to aid in hospital evacuations the 
days before and after the storm hit. Our Prehospital Medical Director 
and emergency room physician, Dr. Greg Frailey provided medical 
direction for our team. Dr. Frailey is one of our regional experts with 
the following experience: 25 years as a naval flight surgeon and 
primary responsibilities to preplan for Mass Casualty Incidents, a 
medical specialist with Pennsylvania Task Force One, the regional 
medical director in Lycoming, Tioga, and Sullivan County, and instructs 
Advanced Trauma Life Support, International Trauma Life Support, PEMA 
blast injuries, forensics, and crush injury classes and many others. In 
2009 the Department of Health purchased portable hospitals to assist 
regions in their readiness. We were the first in the State to set up 
and use the portable hospitals to prepare for the biggest threat to our 
region in regards to mass casualty: The Little League World Series. 
Every August, Williamsport is in the international spotlight which 
carries a heavy responsibility for our emergency preparedness team to 
accurately forecast and take the necessary steps to mitigate potential 
man-made or natural disasters. Little League World Series more than 
doubles the population of Williamsport and a Mass Casualty Incident 
(MCI) is a very real danger that we must consider.
    We're here today to outline several key areas that would be 
relevant to your House Subcommittee. In many ways Susquehanna Health is 
prepared to deal with a mass casualty incident that happens in our 
community. Annually, we meet with our community partners to identify 
external vulnerabilities and update our emergency operations plan to 
mitigate these threats. Our surge capacity is assessed and mass 
casualty plans are updated at this time as well. Surge beds are 
identified in our clinical data systems including pre-defined locations 
throughout our three hospitals. Full-scale exercises and drills 
identify our areas for improvement and best practices. Assistant 
Secretary for Preparedness and Response (ASPR) grant funding helps us 
mitigate our identified needs regarding supplies and equipment. Our 
planning efforts also identify our own internal vulnerabilities.
    Our two emergency departments serve over 60,000 patients a year 
with 43 treatment rooms. Susquehanna Health has started a major 
construction project that will nearly double our emergency department 
treatment capacity. Our geographic location as a regional population 
center in the heart of a large rural tract implies that we will only be 
able to depend on ourselves to service our population during the 
initial stages of an MCI. Lycoming County contains over 1,200 square 
miles of territory. Our closest trauma center is 45 minutes away by 
ground. During a Mass Casualty, we, and many other rural facilities, 
will be challenged to maintain nurse-to-patient ratios, particularly 
during a sustained incident such as a pandemic. In July, 2009, 
Pennsylvania initiated a ban on mandatory over time. While this is 
lauded as a positive step forward in protecting health care workers and 
patients, its wording places burdens on emergency preparedness.
    In response to the many factors affecting health care organizations 
nationally, hospitals are becoming ``leaner'' in staffing, thereby 
reducing any depth for initial and sustained MCI operations. Any 
expectation of rural hospitals to staff alternate care sites during an 
MCI is unrealistic and would further deplete our nurse-to-patient 
ratios and jeopardize patients and staff. Many hospitals, SH included, 
use a just-in-time supply inventory system due to limited storage space 
and as a cost-savings measure. This limits us even further during a 
sustained mass casualty incident. In general, open space to expand 
services into is limited throughout our hospitals. Specialty centers 
within hospitals have their own unique regulations that further limit 
our available spaces. Severe weather and mountainous terrain are 
identified as hazards and can also be contributing factors delaying aid 
to our region in a disaster. Our finite community resources force us to 
plan on little to no law enforcement or security available during an 
MCI. Lack of immunity from prosecution to physicians and other health 
care providers may further limit our response to a disaster for fear of 
prosecution.
    This statement also holds true in regards to our rural hospitals 
receiving casualties from a disaster in a large population center. If 
an MCI happened in a large population center and we were asked to 
receive patients from it, we would have time to prepare ourselves and 
set up our surge beds, create real-time staffing plans, and work with 
our community partners. Our limitations to offer assistance would 
include our liability concerns, and the ban on mandatory overtime. 
Would we be able to mandate staff overtime if the disaster was declared 
in another community and didn't directly affect us? Additionally, with 
few exceptions, there is no current memorandum of understandings 
between our regional hospitals and others around the State.
    The information and direction coming from the Federal Government 
helps to define the expectations for MCI preparation. The Center for 
Domestic Preparedness in Anniston, Alabama offers high quality and 
targeted training on the impact of disasters on hospitals and other 
organizations. SH has sent 40 staff for training at the CDP and 
continues to schedule our leadership to prepare us for the future and 
stay up-to-date on the latest trends and best practices. The National 
Incident Management System (NIMS) courses help tie our National 
disaster response to the local efforts of all agencies involved and 
helps define everyone's responsibilities. The NIMS concept is very 
broad-based and offers a defined framework for response. It also leads 
to confusion at the local level and Federal agencies give conflicting 
guidance on matching training to positions in health care 
organizations. Much of the NIMS training is geared towards the fire 
service. We have made great strides towards full NIMS integration with 
our community partners but further development is needed to adapt NIMS 
to health care organizations.
    Health care looks to the State and Federal Government to help 
satisfy our unmet needs during a disaster or MCI. What can the State 
and Federal Government do to help?
   Currently we are under the conflicting purview of many 
        regulatory agencies to include the Joint Commission, Department 
        of Health, PEMA, FEMA, DHS, HHS, and CMS, all with independent 
        views, and competing interests. Give health care an equal voice 
        in these organizations to ensure that health care needs are 
        anticipated and met.
   Immediate clinical and support staffing during an MCI.
   Financial support to stockpile medications and equipment for 
        an MCI and rapid delivery of additional medical supplies.
   Rapid and mass airlift capabilities with the ability to 
        handle critical patients.
   Rapid deployment of an incident management team or liaisons 
        to hospitals in the initial hours of a disaster with the 
        authority to request Federal resources.
   National phone banks/information hotlines to assist 
        overburdened hospital staff during an MCI or disaster. Rural 
        hospitals will not have the physical capability to handle the 
        volumes of phone calls associated with an MCI.
   Ease EMTALA regulations during a disaster that is not 
        Federally or State-declared.
   Provide funding for Information Technology emergency 
        communication initiatives to support the transfer of patients, 
        and, give care to patients not known to the health care entity.
   Insure all rural hospitals have employee mass notification 
        systems in place.
   Provide Federal templates for health care emergency 
        operations plans and mass casualty incident management to be 
        adopted at the State and local levels.
   Provide funding, mandates, and direction to local health 
        care (not necessarily associated with hospitals) in the 
        planning for mass casualty care. For example: Medical offices, 
        surgery centers, GI centers, eye centers all have nursing, 
        physicians, and other health care workers, but won't 
        necessarily make themselves available to help a hospital if 
        there is a disaster since they are not mandated to do so.
    In closing, I would like to thank Chairman Carney and committee 
Members for the opportunity to provide this testimony and Congressman 
Carney's staff for their assistance and guidance. Susquehanna Health 
considers itself fortunate to be able to maintain a high degree of 
emergency preparedness, but we also acknowledge the obstacles we face 
as a rural health care system with finite human and material resources 
at hand. Our efforts in planning and hazard mitigation can only sustain 
us in the short term and we will look to our State and Federal 
officials for a rapid and coordinated response to assist us should the 
need arise.

    Mr. Carney. Mr. Carnes, please, for 5 minutes, 5 minutes.

  STATEMENT OF GARY A. CARNES, PRESIDENT AND CHIEF EXECUTIVE 
 OFFICER, ALL CHILDREN'S HEALTH SYSTEM, ST. PETERSBURG, FLORIDA

    Mr. Carnes. Thank you, Mr. Chairman and Mr. Bilirakis, for 
inviting me, and to this subcommittee. I think actually 
Congressman Bilirakis gave most of my summary when he 
introduced me. I am here representing primarily children in the 
land of hurricanes. But remember in Haiti 50 percent of the 
population is under 18 years of age, so children are a huge 
factor in disasters and often overlooked. Emergency 
preparedness is not something that happens when an impending 
incident is out there. It must be built in to design staffing 
and it must be funded. Not all hospitals will be equally called 
upon during a disaster. Safety net hospitals, which is what we 
refer to them in Florida, freestanding children's hospitals, 
trauma centers, universities, sole community providers almost 
always get the first wave of victims during any kind of 
disaster or incident.
    The integrity of the building and maintenance of public 
utilities is not assured at all as we saw in Katrina. Buildings 
were often intact but nobody could, and if there were no 
utilities to care for patients and therefore patients had to be 
removed by helicopter from many, many facilities. It took a 
long, long time to remove those patients. Lack of heating, 
ventilating, and air conditioning makes hospitals mostly 
unusable and in fact causes them to become a sick building over 
time. Few hospitals in the United States can maintain 100 
percent of their utilities. Most States require only basic 
emergency electric circuits, red plugs, as we call them in the 
business, to be maintained.
    Patient receipt and removal is a key as you saw in Katrina. 
Clinical readiness is another issue. The required medical and 
surgical expertise doesn't just happen. It must be recruited, 
paid to be retained, on call and available, and has to be kept 
current for its skills. A little bit about the All Children's 
story. We just opened less than a month ago a brand new 259-bed 
quaternary regional freestanding pediatric facility and 
ambulatory complex. The cost was $403 million. Protection was 
providing category 4 and 5 hurricanes, and not all category 5 
because some products didn't come right at that time so we 
built it to the highest standards we could. All exposed 
surfaces were built to withstand high impact wind and objects. 
Our central energy plant provides 100 percent redundant power 
for all utilities, potable water, sewage removal through 
underground systems, and we have about 160,000 gallons of 
diesel on-site underground.
    The patient rooms were built for redundant medical gases 
and electric. Our bed number can go, in the need of a surge, 
our bed number for inpatients could go from 259 to 456 beds by 
just simply bringing in more beds and equipment. Our emergency 
center rooms can double from 27 patient exam rooms to be able 
to take care of 54 due to the equipment size. Trauma rooms can 
be increased from two to six. Our helipad can handle large and 
multiple patient military size aircraft to remove patients or 
bring patients as needed. As a trauma center, we maintain the 
full slate of on-call subspecialists. The cost of this call 
pay, other preparedness costs, are expected to exceed $6 
million per year at our hospital. There is little funding for 
many State or Federal agencies to help pay for these costs.
    In relation to a couple questions that were asked earlier, 
we did build permit decontamination stations into our building 
that can handle 24 patients at a time for chemical and other 
types of insult, and a 28-bed unit of ours can be converted to 
total negative pressure capability in 10 minutes, therefore, 
confining or quarantining patients and their contaminants in a 
room rather than having them exposed to the rest of the 
hospital. That ends my summary.
    [The statement of Mr. Carnes follows:]
                  Prepared Statement of Gary A. Carnes
                            January 25, 2010
                            general comments
    The comments contained herein generally apply to pediatric 
hospitals and health care. However, the same issues, concepts, and 
recommendations apply to adult health care.
    Handling the human injury and illness results of disasters and 
terrorist strikes does not and will not fall equally to all hospitals. 
Key ``safety-net'' hospitals in each community will be called upon to 
meet the initial patient surge demands. These facilities must be built, 
prepared, equipped, and staffed differently. These specialized services 
require specialized capabilities to be available 24 hours/day, every 
day of the year. This is an extremely costly proposition for those 
hospitals willing to make this part of their mission.
                               facilities
    Most hospitals in the United States would not be able to 
accommodate the facilities/physical plant needs for surge patients 
resulting from a major disaster or terrorism strike. In fact, in the 
case of a known and impending potential disaster (hurricane for 
example) many facilities are looking to transfer critically ill and 
fragile patients to hospitals better able to withstand the potential 
insult.
    The integrity of many facilities could be significantly compromised 
by storms or a tornado, let alone a terrorist strike. Because of the 
age of facilities, most hospitals are vulnerable. Just review the 
effects of one storm--Hurricane Katrina.
    A great lesson learned from Katrina was the fragility of public 
utilities and the devastating effects upon hospitals when utilities are 
disrupted. Most hospitals in the United States have only limited, 
emergency power for critical systems and equipment. They cannot produce 
potable water, move sewage, or maintain environmental control over 
temperature and humidity. During Katrina, many hospital structures 
remained well enough intact to provide care, but the building became 
unsafe and ``sick'' due to loss of environmental integrity.
    Generally, most hospitals cannot accommodate patient transfer by 
helicopter. In the case of flooding or other surface disruption, 
helicopter transport may be the only way to deliver or move patients. 
Even in those hospitals where helicopter transport can be accommodated, 
helipads are often on the roof and cannot handle the weight or rotor 
span of large, multi-patient craft. This was a significant complicating 
factor during Katrina. Moving patients one at a time by helicopter is 
extremely inefficient, costly, and potentially dangerous.
    Finally, very few hospitals maintain redundant equipment, supplies, 
or materials on-site for disaster use. Extra space to adequately 
accommodate patient influx is almost non-existent.
                  clinical considerations/requirements
    The vast majority of hospitals in the United States simply cannot 
adequately react to disasters or terrorist strikes that result in large 
numbers of patients with significant injury, trauma, or illness.
    The ``average'' emergency room is not equipped to accommodate a 
significant surge. Generally, only certain hospitals (free-standing 
children's, designated trauma centers, university/teaching) functioning 
as true ``safety-net'' hospitals, have the capacity or available 
clinical expertise to handle a surge of critically ill or injured 
patients.
    In addition to building and systems issues previously discussed, 
the availability of medical and clinical personnel is also a 
significant issue. The ``readiness cost'' just to have certain clinical 
expertise on staff and available, before the first patient is ever 
seen, can easily cost a hospital millions of dollars per year. Trauma, 
general, orthopaedic, otolaryngologists, ophthalmologists, and 
anesthesiologists must all be immediately available as surgical 
specialties. Necessary medical specialists include internal medicine, 
infectious disease, radiology, laboratory, pediatricians, and emergency 
medicine.
    Today, most all of the above specialists demand ``call pay'' to be 
available. Additionally, hospitals must also assure the availability of 
significant non-physician clinical (advanced nurse practitioners, 
nurses, techs, etc.) and support staff to provide adequate response and 
care. These readiness costs for a safety net hospital are staggering--
multiple millions of dollars per year.
                   the all children's hospital story
    We recently opened a new 259-bed state-of-the-art quaternary 
children's hospital and ambulatory building, supported by a complex 
central energy plant, in St. Petersburg, Florida. The cost to construct 
this facility was $403 million. We estimate the extra cost to upgrade 
the facility to meet needed disaster preparedness and patient surge 
requirements was at least $25 million. Documents showing improvements 
we made are attached to this report, but a short list is:
   Central Energy Plant and Fuel Tank Farm--100% redundancy to 
        maintain total environmental integrity and all utilities for at 
        least 2 weeks;
   Upgraded helipad to facilitate large patient transport 
        craft;
   Improved and storm-rated windows, protective walls, and 
        roofing;
   Permanent decontamination stations;
   Additional built-in medical gas and electric for surge 
        capabilities;
   Redundant emergency communications.
    Just to be a trauma center, our readiness (preparedness) costs 
exceed $6 million per year. About one-half is paid as physician call 
pay, and the other half for required additional staff, supplies, and 
equipment. Very little Government financial support is received to 
offset these costs. Maintaining trauma readiness is a key benefit to 
accommodate patient surge due to a disaster or terrorist strike.
    Specific surge capabilities, built into the new facilities to 
accommodate patients from disasters and strikes, include:
   Emergency Center equipped and sized to go from 27 to 54 
        patients;
   Neonatal Intensive Care could be increased from 97 to 132 
        beds;
   All other inpatient rooms could increase from 162 to 324 
        beds;
   An entire 28-bed unit can be easily converted to negative 
        pressure, allowing the quarantine and control of infectious 
        patients;
   Redundant warehouse storage to maintain and rotate supplies 
        and stores for disaster requirements.
    These capabilities, as previously noted, were not inexpensive. But 
as the only free-standing, quaternary, regional pediatric center on the 
west coast of Florida, we felt these ``upgrades'' were necessary to 
maintain services to the population.
    We cannot move our patients during a disaster or terrorist strike--
no other facility can provide all the necessary clinical services. We 
usually receive a minimum of forty (40) patient transfers to All 
Children's when a storm is approaching. These are sent by other 
facilities who fear they will not be able to provide the necessary 
care.
    We are fortunate to have been able to build our new hospital to 
accommodate most surge capabilities. We are likely one of few hospitals 
in the United States that can adequately meet these demands. Paying for 
this ``readiness capability'' is expensive and an on-going struggle.

    Mr. Carney. Thank you, and I thank everyone for their 
testimony. Since I understand you are on a tight time frame, 
Mr. Carnes, I will yield the first round of questions to my 
good friend, Mr. Bilirakis.
    Mr. Bilirakis. I would like to welcome the entire panel, 
and I want to address my first round of questions to you, Mr. 
Carnes. I know you have to catch a plane. All Children's 
Hospital, everybody knows now, just completed a successful move 
into a new state-of-the-art building. It is a fantastic 
facility. If you ever come to Tampa Bay, please come and visit 
us. A couple questions. What new capabilities will you have in 
this new facility?
    Mr. Carnes. From a clinical standpoint, not a lot of new 
clinical programs because we were already providing certain 
programs in a State that no one else even provided from a day-
in, day-out clinical programmatic area such as transplants and 
things like that. But from emergency preparedness the fact that 
we can stay as an island for 2 weeks or more due to the backup 
redundant systems we have built makes us totally different than 
currently any other hospital in Florida. So unless there is an 
earthquake or a tornado rips the building apart or it is a bomb 
or something like that, we can produce all water, electric, 
move sewage. We can do everything that is needed.
    We also built into the capability a redundant warehouse and 
what we do is we move stores into the warehouse, bring them 
into the hospital and replace those, so we have an on-going 
rotation of stores, but it serves as an duplication of stores 
and supplies on-site so that if needed we cannot take delivery 
for quite some time and still maintain our ability to care for 
patients. We also included in the building, we built an 
interstitial floor so that there is no air handling equipment 
or anything like that exposed to the environment. They are all 
in the middle of the building on an enclosed fourth floor, so 
they can't be reached by sunlight, wind, damage, those kinds of 
things.
    Mr. Bilirakis. You probably addressed this to a certain 
extent but what unique challenges to treating children or other 
special needs populations present during an emergency?
    Mr. Carnes. For most hospitals, they don't have the variety 
or sizes of equipment and supplies needed to take care of kids 
everywhere from newborn up to adolescents, and that is probably 
the biggest challenge that hospitals have is not the supplies 
necessarily but also clinical expertise to recognize conditions 
in children and then treat them properly.
    Mr. Bilirakis. Very good. The H1N1 outbreak this fall 
disproportionately impacted children, as everyone knows. What 
impact did it have on operations at All Children's?
    Mr. Carnes. We had about a 40 percent increase in emergency 
room traffic for about 3 months, mostly related to H1N1. We 
have to move one of our--we had to maintain our primary 
emergency room, this was in the previous facility, for those 
patients and moved to a secondary waiting room for other 
patients, which really was part of our lobby. So in the new 
building we have designed our emergency room with three or four 
different waiting rooms, a main waiting room and then built 
into it three or four separate sub-waiting rooms where we can 
put patients of different types. As I mentioned, we can double 
the amount of our emergency room capabilities simply by rolling 
in more beds if we need to.
    Mr. Bilirakis. Thank you, Mr. Chairman, I appreciate it.
    Mr. Carney. Thank you, Mr. Bilirakis. Mr. Carnes, I think I 
am asking this question on behalf of your Pennsylvania 
colleagues. Certainly I am interested. What is the source of 
your funding for that hospital?
    Mr. Carnes. We put $200 million of our own cash into it and 
we took debt for $200 million. We basically had no debt on our 
old building so it was all new debt. Our old building was about 
42 years old. We did receive for our helipad upgrade from FEMA, 
we received three-quarters of a million dollars. That was the 
delta between what our helipad would have cost us and the 
oversized helipad. We also through HHS received $4.9 million, I 
think it was, to make sure we had the most up-to-date 
diagnostic equipment in the radiology suite that we wanted.
    But we had already--also I--invested fully in a full 
electronic medical record system. We have tele-medicine 
capability to all our facilities on the west coast of Florida 
and we have full picture archiving and transmission and receipt 
of diagnostic images on that system too.
    Mr. Carney. Very impressive. This question is for the 
entire panel. In an effort to prepare for and medically respond 
to a large-scale disaster, whatever it may be, man-made, 
natural, whatever, there has got to be a true partnership 
between the Federal Government, the State government, and the 
local hospitals. From your perspective, for the whole panel, 
does that relationship exist, and, if not, what do we need to 
do? Dr. Skiendzieleski.
    Dr. Skiendzielewski. I think you are correct. I think that 
if something happens immediately I think our response is we 
initially do the best with what we have and what we can. We try 
to hold on, hold on till the cavalry arrives. I think over the 
last several years the cavalry has come through for us. 
Pennsylvania has certainly developed through our communications 
network and through the local hospitals and through the caches 
that we have available enabled us to hold on and go a little 
beyond that. In the case of a significant even which would 
exceed even those types of responses, I think FEMA then would 
have to come in and take place. I am not exactly sure that I am 
confident about that part of it.
    Mr. Carney. Sure. Sure. Mike O'Keefe.
    Mr. O'Keefe. Thank you. I think it is important that 
representatives of various agencies need to meet and develop 
relationships under non-stressful circumstances before they 
need to meet and take action in a crisis situation. I think at 
a local level, I think we are very fortunate. Evangelical 
Hospital is located in the North Central Task Force region, 
which includes I think seven counties and 11 hospitals. We are 
very fortunate because of our unique geographical location, we 
also have a mutual alignment with the east central, which would 
be Geisinger Medical Center and Sunbury Hospital and like that 
in our area. So I think at the local level we have good rapport 
and a good relationship.
    I think a concern that I would have would be complacency 
between the State and the Federal level. I think it is 
important that, as I mentioned, organizations and 
representatives of different agencies, meet and develop 
relationships so they will know who to call and what their 
capabilities are again in non-stressful situations because 
unfortunately a crisis situation is going to happen.
    Mr. Carney. Next.
    Mr. Kane. My answer is very similar. If you just look at 
the agencies involved, you have got Joint Commission, 
Department of Health, PEMA, FEMA, DHS, HHS, and CMS. These 
agencies all have a different purview and regulations. If you 
just take the regulations that we come under related to Joint 
Commission and Department of Health, and they review us 
regularly, their requirements are different, and there should 
be some uniformity in this area.
    Mr. Carney. That is interesting.
    Mr. Carnes. We in Florida face every April 1 basically the 
beginning of another hurricane season so we are pretty 
accustomed to planning for and trying to come up with plans to 
mitigate the problems of a disaster of that type. The States 
has an active program in Florida. They have an annual 
conference for disaster preparedness, and FEMA, I believe, does 
send people to participate in that. But like the others there 
is always that question about the alphabet soup of agencies and 
whether they will all be coordinated. We saw a little problem 
with that when the hurricane came through Homestead a few years 
ago, and we certainly saw problems when Katrina went through 
New Orleans. But I would say in our State we just, due to where 
we are and what we face, we have probably a little closer 
relationship with FEMA because they are in our State quite a 
bit more maybe than they are other States.
    Mr. Carney. Thank you. Mr. Bilirakis.
    Mr. Bilirakis. I have a couple more questions for Mr. 
Carnes. What lessons from the recent move can you use to 
enhance your evacuation or other disaster plans?
    Mr. Carnes. Well, I think we learned that nothing is as 
easy as it looks sometimes, and that you need to be prepared 
and even more prepared. We spent 2 years just planning to move 
the patients on paper, doing mock moves, putting patients in 
beds and moving them, kids of workers and things. We did that 
many times, and I think that helped us during the day of the 
move. That is the kind of thing that will help us if we ever 
have to move patients, I think, during a storm, but we tried to 
build in as many redundant and safety features into the 
hospital as we could. It cost us at least a minimum of $25 
million more to do that and probably more than 10 percent of 
the cost of the hospital if we had counted for all the delta 
between what we could have gotten by with and what we ended up 
doing.
    Mr. Bilirakis. Would you please share us the experiences 
All Children's has had trying to access Federal funds for 
increasing surge capabilities and making improvements to 
respond to the community needs in general?
    Mr. Carnes. Yes. As I mentioned, we did receive two grants, 
one from FEMA for the helicopter pad, and one from HHS for some 
diagnostic equipment. The issue we ran into, and it even kept 
going through the stimulus funding, was that we began this 
project, planning this project, more than 7 years ago, and it 
took us about 3.5 years to build the project. Because we had 
already put caissons in the ground, we hadn't built the 
building yet or anything, but we had started to put the 
foundation in, we were told we were ineligible for a lot of the 
Federal funding to do some of the things we did simply because 
we had already begun the project, and they did not approval 
status over that project because it was already designed, 
obligated, et cetera, et cetera, even though they told us that 
they would have liked a lot of the things that we did. We 
weren't eligible for the funding because the project had 
already physically begun.
    We were able to get the helicopter pad through your office 
and Congressman Young's office and a few others because we had 
not actually started construction on the helicopter pad at the 
time so that is why we were able to get the little bit of money 
from FEMA to help offset that additional cost.
    Mr. Bilirakis. Thank you. For the entire panel, how 
frequently does your hospital exercise its emergency response 
plans?
    Dr. Skiendzielewski. The Joint Commission requires us to 
have our response, our disaster plans, at least once yearly 
where we actually have casualties, mock casualties, enter the 
hospital. In addition to that, we also will have drills on 
other portions of our plant. We have a nuclear power plant 
about 20 miles away, and every year we work on decontamination 
with the nuclear power plant. We do mock weather disaster 
drills. We will do mock infrastructure failure drills, and 
these are all done at least annually. In addition, we will have 
actual events which can occur. We mobilized our Incident 
Command System last summer when we had a water leakage in one 
of our pipes, so we look for opportunities in order to do that 
in order to maintain our preparedness and our capabilities.
    Mr. Bilirakis. Thank you. Dr. O'Keefe.
    Mr. O'Keefe. I think most hospitals, as the doctor said, 
almost on a daily basis go through exercises that can only be 
replicated in a drill situation. We actually have better 
response on a day-by-day basis than we do when we have drills 
per se because people in the back of their mind they know it is 
a drill. It is an exercise. At the same time all the emergency 
departments seems to be ready in case that unfortunate bus 
accident happens or in this part of the country if a loaded 
buggy gets hit unfortunately we need to be able to handle 
things like that. But really the drills, we do exercises in 
concert with other area facilities on a regular basis 
throughout the course of the year utilizing not only health 
department but also local agencies as well.
    One concern, if I could go back over here as well regarding 
that, is our critical concern, is response reliability. 
Unfortunately, it has been shown through Katrina that 50 to 80 
percent of the responders sometimes health care workers will 
not report if they are concerned about their families, their 
immediate families may be in danger. So responders' support 
must not be taken for granted or just assumed that it is 
automatically going to be there. That is something we need to 
work on and just keep in the forefront of our minds as well.
    Mr. Bilirakis. Thank you.
    Mr. Kane. At Susquehanna Health we have invested in a 
coordinator of emergency preparedness that specifically focuses 
full-time on drills and training. He is with us here in the 
audience today. He was at Hurricane Gustav as part of our 
response team. We drill multiple times a year. We have 
something going on probably monthly. Probably most important in 
our system is the fact that we have sent 40 individuals to 
training at the Center for Domestic Preparedness in Aniston, 
Alabama for the Incident Command Training, and that is a big 
part of our process.
    Mr. Carnes. We--as a trauma center, we are pretty much 
ready 24 hours a day, 7 days a week, to take whatever happens. 
As I mentioned, we have all needed subspecialties on call. We 
have made some arrangements for some people to sleep in during 
disasters so that we can keep staffing people, and we have set 
our plan so that if you are there and come in, you are not 
leaving until we can replace you so it is--and people sign up 
for it. It is a known plan so we try to do that. In addition to 
just being ready as a trauma center, we have at least two of 
our home full drills a year of our emergency preparedness. The 
county also has an all-hospital drill date at least once a year 
and you get mock casualties from that. We never know what the 
casualties will be until they get there.
    Then as a hurricane State, we are almost always at least 
once or more times a year call our plan into process just 
simply because we don't know where a storm is going to go. With 
our new emergency system, our central energy plant, we have 
obligated ourselves to run that thing for a full day once a 
month just to make sure that it is operating properly.
    Mr. Bilirakis. Thank you. Thank you, Mr. Chairman.
    Mr. Carney. This is primarily for the Pennsylvania 
contingent. It is great to hear that each one of the hospitals 
does the drilling, does the preparation for what is likely to 
affect us, and thankfully we almost never deal with a 
hurricane. We deal with remnants of hurricanes occasionally but 
usually not the full force. Do you do this as individual 
hospitals or do you work together in preparing for something 
that might happen regionally? Susquehanna, do you talk to Evan, 
and, Evan, you talk to Geisinger, and, Geisinger, do you talk 
to Susquehanna and back and forth when you do these plannings?
    Dr. Skiendzielewski. As I mentioned, we started doing this 
30 years ago. We developed an inter-hospital plan including 
Evan. It didn't extend quite up to Williamsport but it did 
include Muncy Valley Hospital. We think that it is essential 
when we plan to have communications, and the reason that we did 
this plan in that way is because of resources that needed 
perhaps to be shared. We needed to know where is the best place 
to take patients, to accept patients, and that seems to work 
out very well for us.
    Mr. O'Keefe. I would echo that, and also we may not have 
the hurricanes that Florida has, but Interstate 80 seems to be 
a break point in weather. I remember a couple years ago there 
was a massive wreck, series of wrecks up there, that I believe 
all the hospitals in the area were called upon to react to, a 
weak link or Achilles heel, if you will, through this. We do 
also participate with the other area facilities on planning for 
this, as well as trying to coordinate response. But a weak link 
that may--and I can go back and emphasize what Dr. 
Skiendzielewski mentioned is that the rural area, rural 
situations, the emergency responders oftentimes are volunteers, 
and that is very difficult to draw upon, I will say Monday 
through Friday 9:00 to 5:00. Even sometimes nights and weekends 
they can be bare bone as well, but that is an area of need to 
somehow help shore that up.
    Mr. Kane. I would add to what has been said with, yes, I 
think there needs to be more planning communication between the 
hospitals and the rural area. One of the recommendations we had 
in our testimony was for the Federal or State support to 
provide a way for hospitals to get together to do more 
cooperative planning. There is plenty of planning code within 
counties. There is planning amongst county providers. There is 
county plans and so on. There is regional plans, but most of 
those are focused between how the hospital deals with school 
systems or counties or public of whatever, but as far as what 
happens supporting each of the hospitals in the area, it is 
mostly done by hospitals that are closer together. It should be 
more regional.
    Mr. Carney. Have you ever planned--I am sorry, Mr. Carnes. 
I will get to you in a second. Have you ever planned between 
the three of you and other hospitals, say Shamokin and Sunbury 
and Muncy, as one event? Has that ever happened?
    Mr. O'Keefe. Yes, we have.
    Mr. Carney. How often do you do that?
    Mr. O'Keefe. Probably not often enough compared to the 
subcommittee here, but we have had mutual facility exercises 
where we have even had observers in from the State level making 
sure that those are coordinated events. For example, if it was 
the Bureau of Prisons or if it was at the local nuclear power 
plant, we have coordinated activities and exercises.
    Dr. Skiendzielewski. Yeah, that was the whole premise of 
that inter-hospital plan that everybody works together to make 
it happen.
    Mr. Carney. But you do exercise. It is one thing to plan. 
It is a whole other thing to actually do it. I appreciate that. 
Mr. Carnes, and I assume you have the same kind of relationship 
with hospitals in your region?
    Mr. Carnes. Yeah, as I said, our county does formal 
planning, our region does formal planning and formal exercising 
so twice a year in the county and once a year on a regional 
basis we do formal exercises and get different patients in. We 
just see what comes in during those, but, yeah, we do that in 
Florida.
    Mr. Carney. You have all mentioned, perhaps, and I hope it 
is not, but it sounds like there might be an increasing 
shortage in emergency medical technicians and first responders. 
Is that your experience?
    Dr. Skiendzielewski. Well, I don't know if they are not--if 
they are decreasing, but again the rural area is just so much 
different than the urban area, and what we find is our 
volunteers now sometimes are working two jobs, and they just 
don't have the time to do ahead and volunteer as much as they 
would like. To compensate, a lot of our ambulance companies, 
EMS services now, are hiring people so they do have to employ 
some folks and then fill in with volunteers on shifts when they 
still are able to do so. So it is changing a bit but I think 
that we still have enough people that are interested I doing it 
such that that is not a real issue for us although I am sure 
that if we were able to assure the availability by having more 
paid positions that would put us at better stead.
    Mr. Carney. Is there any sense of the number of how short 
we are in terms of responders? Do we have enough but we just 
don't have it at the right times, we don't have enough?
    Dr. Skiendzielewski. I don't have a real sense of that, 
sir. I know that people in this area when somebody needs to go, 
they go.
    Mr. O'Keefe. One of the other compounding factors, it is a 
back-handed compliment, is that the expectations, the training, 
the regular annual updates that have to happen are becoming 
more onerous. It is a good thing because the people that 
respond are that much more skilled and better trained but it is 
extra demands on their time when they are already busy people.
    Mr. Kane. I can only respond to our area of Northeastern 
Pennsylvania. I can't think of any volunteer fire company in 
our area that wouldn't say there wasn't a serious staffing 
shortage related to EMT personnel. It is a significant issue, 
and as a hospital system, we become a staffing company 
basically to provide staffing to those local ambulance 
services.
    Mr. Carnes. We are an urban area. There is really not a lot 
of volunteer fire and other types of organizations. They are 
mostly paid, and they do respond if they are required but 
making sure they stay is another issue sometimes. Our bigger 
issue for us is that, and this has to do just with pediatrics, 
is the shortage and the impending real critical shortage of 
pediatric specialty care people. There are only about 12 
people, 12 people graduating from training program and 
pediatric neurosurgery in the United States this year, about 12 
in orthopedics, so if you look at spreading those across 50 
States, 43 freestanding children's hospitals, and probably a 
couple hundred other places that have some pediatric beds it is 
a real problem. It is going to be a real problem for those in 
the future as the population grows, and there are a variety of 
bills before Congress to do some things about the training 
programs and the universities, but for pediatrics it is a 
significant problem in the future.
    Mr. Carney. Thank you. Mr. Bilirakis.
    Mr. Bilirakis. Thank you. This is for the entire panel, but 
I know, Mr. Carnes, you have to leave. I don't want you to miss 
your plane, so if you can address it first. What are the three 
most important things that could be done to increase hospitals' 
ability to surge? What assistance can be provided by the 
Federal Government? This is your chance. Not simply in terms of 
funding, but also in terms of personnel, guidance, or other 
resources, what more could the Federal Government do to assist 
you to enhance your medical surge capacity?
    Mr. Carnes. Well, if you don't want to talk about funding 
for buildings, people. I mean you have to have the people. No 
matter how good of a building, you still have to have the 
people in there, and for pediatrics there is a significant 
shortage of those people, not just physicians but mid-level 
practitioners, nurses, those kinds of people. There is just not 
a lot of pediatric training for people done in their primary 
education whether they are physician, nurse, or whatever they 
might be. So additional training slots for a variety of 
physician and non-physician for hospitals. The other is better 
coordination, I would say, with different agencies and quick 
strike response when there is a problem. We have built for the 
inevitable that we would be alone 2 weeks. I don't think that 
will ever happen just due to where we are and the assistance I 
know we will get. But you have to--the government, whether it 
is State, local, Federal needs an ability, I believe, to have a 
quick strike response with food supplies, fuel, whatever might 
be needed or to transfer patients from facilities that can't 
make into facilities it can.
    Even during a normal hurricane, we generally get 40 to 50 
patients transferred to us long before the storm ever gets 
there who are medically fragile patients in long-term care 
facilities and things like that, so our sense is we will go up 
40 to 50 even during any storm, and they get there in a variety 
of ways, not all of them very good, sometimes just brought by 
their families in a car because they are concerned, so those 
things could be--if they were better planned and better 
executed would help the patients and the response, I believe.
    Mr. Bilirakis. Thank you.
    Mr. Kane. I appreciate the question because I wasn't able 
to answer and give my recommendations earlier. First of all, I 
would say three. Financial support to stockpile medications and 
equipment for mass casualty incidents and rapid delivery of 
additional medical supplies is paramount. Two, I would say 
rapid deployment of an Incident Management Team or liaisons to 
hospitals in the initial hours of a disaster with the authority 
to request additional Federal resources. Third, I would 
probably say something that reinforces what I said earlier, 
provide Federal templates for health care emergency operations 
plans and mass casualty incident management to be adopted at 
the State and local levels so we have some uniform templates.
    Mr. Bilirakis. Thank you very much.
    Mr. O'Keefe. I think Mr. Kane hit on some of the critical 
components. Some of the things I would add to that would be 
consistency of information technology, not only capabilities 
but also the language that is necessary between institutions 
and organizations. Likewise, even just communication 
capabilities, as I pointed out, that is often the greatest need 
but it is often the weakest link there as well, so I think 
those would be additional pressing needs that need to be 
addressed or could be better served.
    Dr. Skiendzielewski. I think Mr. O'Keefe was looking at my 
expressions here. ITF, I think, is huge. Working an emergency 
department day-by-day, there is a tremendous amount of 
redundancy that we have to accomplish when caring for 
critically ill or injured patients. Folks get expensive tests 
done at one hospital, and then they come to ours sometimes they 
are repeated because their X-ray information just doesn't talk 
to ours. I think that if we could find some way to universally 
connect infrastructure, that would certainly help a great deal, 
and it would help with the communications part of it as well.
    Mr. Bilirakis. Thank you very much. I yield back the 
balance.
    Mr. Carney. In addition, I want to echo what you have all 
said. I think we need real broadband in a big way through here. 
I think that would facilitate all of this, and I know that is 
something we are all focused on in Washington is getting that 
done. I am not sure how to phrase this. I am kind of happy Mr. 
Carnes has departed because he is from the urban area. Is there 
a difference between urban and rural in terms of resourcing for 
natural disasters or man-made disasters? Is there a difference 
in the funding that comes and how it is looked at in terms of 
need?
    Dr. Skiendzielewski. Sure. I think that the two biggest 
things that we are talking about when we talk about rural 
versus urban is, first of all, the distances that are involved. 
In Philadelphia where I grew up, there is a big hospital 
probably 2 miles away from one another. Here, we have 
situations of transport and terrain and weather. Our 
helicopters are--the reason why we have five helicopters is to 
overcome those obstacles. When you have a huge incident, and 
maybe it is just a bus that turns over, nevertheless that is a 
significant, significant issue for us in the rural area because 
of the transport that is involved.
    The second, again coming back to the capabilities of the 
pre-hospital care providers that you have. One of the key 
things that you have to do when there is a mass casualty 
incident is to do triage. In order to do triage well, you have 
to do triage on more or less a regular basis. One of the things 
that our helicopters provide us with is real experience pre-
hospital care, medics, and nurses on the helicopter that can 
get to the scene and do that. However, if it is bad weather, we 
very well may be relying upon someone who has very little 
experience or very little training in this crucially important 
portion of our response.
    I think in the urban areas, I think they see this quite 
frequently and so that certainly is a difference. Then you have 
your choice when you are in a city of which trauma center you 
are going to go to. Are you going to go to Jeff, are you going 
to go to Penn, are you going to go to Hahnemann? Well, you 
know, here if you are making those choices, you are talking 
about an hour's helicopter ride perhaps to go some place else. 
So I think there are really vast differences.
    Mr. Kane. I think Dr. Skiendzielewski said that very well. 
I would add one of our recommendations was the National Phone 
Banks information hotlines to assist overburdened hospital 
staff during an incident. Rural hospitals will not have the 
physical capability to handle the volumes of phone calls 
associated with these types of events.
    Mr. Carney. Does being in a rural area mean that you don't 
get enough information, do you think, do you not get adequate 
funding because it is urban versus rural? Is there any formula 
that would make sense that would fit when we are talking about 
Federal funding and State funding?
    Mr. O'Keefe. We probably would need to have our chief 
financial officers here because I think you are leading with 
our chin as far as feeling as though it is rural versus urban, 
and feeling as though in central Pennsylvania, speaking for 
myself but I think my colleagues would agree, this is a lower 
cost area to provide care, and, therefore, we also receive what 
I am going to say is a disproportionate decrease or discount in 
what we are funded.
    Mr. Carney. Okay. For emergency preparedness for your 
ability to respond.
    Mr. O'Keefe. Across the board.
    Mr. Carney. Okay. Dr. Skiendzielewski, do you want to add 
to that? You are not going to touch that one? Okay. Mr. Kane, 
you said that you would like more guidance on the Federal 
Government? We don't have enough guidance for you? What sort of 
guidance would you like to see?
    Mr. Kane. Well, that is always a double-edged sword but 
what I am specifically referring to is uniformity and in 
templates and in how we approach emergency preparedness 
planning and how we respond to it, what the requirements are, 
how will we be inspected by different agencies that have 
expectations of us. So it is guidance in coming up with 
something that is equitable among all rural institutions and 
that it is effective in helping us cooperate with each other.
    Mr. Carney. There are a number, as you are aware, of 
Federally prepared response criteria and plans out there. Are 
they not helpful?
    Mr. Kane. Not for the rural areas.
    Mr. Carney. I see.
    Mr. Kane. I think there is a big difference.
    Mr. Carney. Okay. Mr. Bilirakis.
    Mr. Bilirakis. Thank you. The outbreak of the pandemic flu 
we have been experiencing has been seen as a test case by many 
experts to demonstrate how well prepared we are for a large-
scale medical crisis. I have a couple questions here, and for 
the entire panel. What lessons did you take away from the H1N1 
pandemic this fall? Did it test your surge capacity? Did your 
hospitals face overcrowding in a waiting room area or intensive 
care units? Did your hospitals face staff shortages due to the 
illness either of the personnel or their families? Whoever 
would like to start first.
    Mr. Kane. I guess I will lead off on that. As far as 
additional volumes, we probably had an additional 25 percent 
volume in the emergency department which translates to about 60 
patients a day at that time which definitely stresses any rural 
system. Some of the things that we learned, immediate education 
for a lot of folks with flu-like symptoms to stay home rather 
than coming to the hospital is important. We actually developed 
a surge capacity area next to the emergency department as a 
result of this so that we can easily provide more treatment 
areas as needed.
    The challenge in this is having enough provider staff 
available during these events, and while there has been some 
ease in how we credential additional staff to come in and do 
that, there are still legal and liability implications about 
bringing staff into an institution that aren't regularly 
working there who are not employed by the institution so from 
the State level we are allowed to bring in additional folks. 
The question has not been answered yet related to the liability 
of not doing an exhaustive screening of providers coming in to 
a facility.
    Mr. O'Keefe. Volumes in our emergency department during the 
first or second wave did increase probably about 15 or 20 
percent. Fortunately, not many of those resulted in admissions, 
in patient admissions. We were able to actually care for most 
of those people. Our concern is the communication that happens. 
Unfortunately, sometimes the media can heighten some concerns, 
and we want to make sure that the appropriateness of the words 
that are delivered to the population are that they can 
understand, wash your hands, stay at home, like that. We were 
also able to make alternate site arrangements so that we could 
segregate those individuals who thought they had some type of a 
flu-like illness so that they were not congregated in the 
emergency department main waiting room proper so we could try 
to isolate them and begin appropriate care on an earlier basis.
    Dr. Skiendzielewski. I think some of our experience echoes 
some of the numbers that you have heard from Williamsport and 
from the Evangelical Hospital as far as our increases in 
patients seen. What I have learned from this was that in this 
instance you can't put together a plan and then that is the 
plan. As an emergency physician, we are used to being a little 
shifty in trying to do things on the fly, and that is exactly 
what we did with the flu in emergency medicine. Things would 
change from day to day. There would be new directives out on 
who to treat, who not to treat, should you do a test, should 
you not do a test. You needed to basically apply those and do 
updates every 24 hours.
    Based on that, I think that helped us get through some of 
the issues that we faced. I think the health system in general 
did a great job as far as getting their employees vaccinated 
and getting the patients in their--we have multiple primary 
care sites through the region, and those folks were getting 
their primary care patients vaccinated. The message went out. 
If you have the flu and you are not in one of the high-risk 
groups then probably you should stay home and take care of 
yourself, and that message got out early very well.
    We did not see any staff shortages, I think mainly because 
90 percent of our folks got vaccinated, and the other 10 
percent washed their hands all the time and wore masks. We made 
the patients that came in and visitors that came into the 
hospital all had to--if they had any signs or symptoms of flu, 
they had to wear masks as well, so I think we did a great job 
at mitigating the effects of this for ourselves.
    Mr. O'Keefe. If I can, just one more quick comment about 
that. I think because you can see it coming, we actually 
participate, Evangelical along with Geisinger, Sunbury, 
Bloomsburg hospitals, and the like, Bucknell University, 
Susquehanna University, Bloomsburg University in coordinating 
efforts planning for what can we do, so to your points about 
preparation and anticipating some of this, I think some of 
those actions ahead of time play off to the benefit of the 
community at large.
    Mr. Kane. We had a similar experience in our three 
hospitals, the local, Lycoming College, Penn College and other 
local facilities. We cooperated with each other on what we were 
doing and what we were communicating. That was very important.
    Mr. Bilirakis. Thank you. Yield back the balance. I don't 
have any time left.
    Mr. Carney. Yeah, there is always the possibility that we 
will have some kind of mass casualty event in New York or 
Philadelphia or even Tampa for that matter. Do you share 
information back and forth of hospitals in those regions? Do 
you exercise with them? Is there some kind of planning that 
might go on in case they had to evacuate citizens or patients?
    Dr. Skiendzielewski. The best we had was the FRED system 
which is basically a Pennsylvania-based system. We don't 
regularly do drills from that extent to Philadelphia and those 
areas.
    Mr. Carney. Outside the FRED system, which can be flawed at 
times, I think it works decently but it can be flawed, have you 
developed kind of those interpersonal relationships? Is there a 
phone call? Is there somebody you can go talk to and say, look, 
you know, this has happened. Can you take on 50 or however many 
folks?
    Dr. Skiendzielewski. I am not sure about 50, but certainly 
we have personal contacts with folks in Philadelphia and 
Pittsburgh and Allentown area, Scranton, their hospital in the 
valley as well, and certainly we haven't been asked to do that, 
but certainly if they were overwhelmed we certainly would 
respond. The fact that we have the transportation capabilities 
with our five helicopters puts us in a good position in order 
to assist with that if we were asked to do so. We were put on 
standby for 9/11. As a matter of fact, if we needed to respond 
there we would have been able to go ahead or else backfill some 
of the EMS facilities in New Jersey that went into New York. So 
we are always ready to help in those instances.
    Mr. Carney. So from that perspective God forbid another 9/
11 happened, are you all, I wouldn't say on the hook, but are 
you all prepared or in some kind of chain to respond if there 
are ripple effects this far west?
    Dr. Skiendzielewski. I don't think that there is a formal 
chain that has been developed but certainly we will be ready.
    Mr. O'Keefe. I know that Evangelical Hospital had two of 
our nine emergency room physicians just spent the last week in 
Haiti along with five of the nursing staff, so not only is it 
our own homeland that we are ready to respond to but as 
necessary beyond as appropriate.
    Mr. Kane. We also had emergency physicians from two of our 
emergency departments that are in Haiti. We responded to 
Gustav, as I mentioned earlier, and I do think there is 
communication back and forth, but I think there could be a more 
planned formal process of drilling with other institutions 
further away.
    Mr. Carney. Well, gentlemen, I want to thank you for your 
time and your testimony. I think it is valuable to get the 
perspective of the folks on the ground who could be impacted. 
The challenges you face in the rural area certainly--there is a 
lot of rural hospitals out there in this country, not just in 
the tenth district of Pennsylvania certainly. Your perspectives 
are most appreciated. If we have further questions, we will 
contact you and I anticipate there will be further questions. 
But with that, this subcommittee stands adjourned. Oh, excuse 
me.
    Mr. Bilirakis. I wanted to thank the city of Danville for 
hosting us here today, and I want to thank our Chairman here 
who--I know you hear a lot of horror stories of Washington, DC 
about the lack of bipartisanship but it doesn't happen in this 
subcommittee. We work together, and it should be that way all 
over particularly with Homeland Security. I understand, Chris, 
you are working on maybe having a hearing in Florida. I know 
that is a great sacrifice during this time of year but we look 
forward to you coming down. Thanks so much.
    Mr. Carney. Thank you, Mr. Bilirakis. With that, the 
subcommittee stands adjourned.
    [Whereupon, at 1:50 p.m., the subcommittee was adjourned.]

                                 
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