Department of Health and Human Services

OFFICE OF 

INSPECTOR GENERAL 

 

STATE AND LOCAL PANDEMIC 

INFLUENZA PREPAREDNESS: 

MEDICAL SURGE 

 

Daniel R. Levinson 

Inspector General 

September 2009 

OEI-02-08-00210 
Office of Inspector General 

http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the integrity of the Department of Health and Human Services 

(HHS) programs, as well as the health and welfare of beneficiaries served by those 

programs. This statutory mission is carried out through a nationwide network of audits, 

investigations, and inspections conducted by the following operating components: 

Office of Audit Services 

The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 

audits with its own audit resources or by overseeing audit work done by others. Audits 

examine the performance of HHS programs and/or its grantees and contractors in carrying 

out their respective responsibilities and are intended to provide independent assessments of 

HHS programs and operations. These assessments help reduce waste, abuse, and 

mismanagement and promote economy and efficiency throughout HHS. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 

HHS, Congress, and the public with timely, useful, and reliable information on significant 

issues. These evaluations focus on preventing fraud, waste, or abuse and promoting 

economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI 

reports also present practical recommendations for improving program operations. 

Office of Investigations 

The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 

of fraud and misconduct related to HHS programs, operations, and beneficiaries. With 

investigators working in all 50 States and the District of Columbia, OI utilizes its resources 

by actively coordinating with the Department of Justice and other Federal, State, and local 

law enforcement authorities. The investigative efforts of OI often lead to criminal 

convictions, administrative sanctions, and/or civil monetary penalties. 

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

OIG, rendering advice and opinions on HHS programs and operations and providing all 

legal support for OIG’s internal operations. OCIG represents OIG in all civil and 

administrative fraud and abuse cases involving HHS programs, including False Claims Act, 

program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG 

also negotiates and monitors corporate integrity agreements. OCIG renders advisory 

opinions, issues compliance program guidance, publishes fraud alerts, and provides other 

guidance to the health care industry concerning the anti-kickback statute and other OIG 

enforcement authorities. 
Δ EXECUTIVE SUMMARY 

OBJECTIVES 

To determine the extent to which selected States and localities have: 

1. prepared for a medical surge in response to an influenza pandemic 

and 

2. conducted and documented exercises that test their medical surge 

preparedness for an influenza pandemic. 

BACKGROUND 

An influenza pandemic is a global outbreak of a highly infectious 

influenza virus that can cause serious illness in humans. The 

Department of Health and Human Services (HHS) estimates that even 

a mild influenza pandemic could cause between 2 and 7.4 million deaths 

worldwide. In February 2008, the Assistant Secretary for Preparedness 

and Response (ASPR) within HHS asked the Office of Inspector General 

to evaluate State and local preparedness for influenza pandemic, 

particularly with regard to medical surge and vaccine and antiviral 

drug distribution and dispensing. 

Since 2002, HHS, primarily through ASPR and the Centers for Disease 

Control and Prevention (CDC), has provided more than $8 billion for 

programs to enhance their emergency preparedness for large-scale 

public health emergencies. In addition, HHS provided $600 million in 

supplemental funding specifically for pandemic influenza preparedness. 

If a severe pandemic occurs, it will affect much of the country at the 

same time, so medical resources—such as hospital beds, medical 

equipment, and personnel—will likely be scarce. The ability to rapidly 

respond to an increased demand for medical resources is often referred 

to as a medical surge. This study focuses on the following five key 

components of medical surge that are based on guidance from ASPR and 

CDC: (1) coordination among stakeholders; (2) recruitment and 

management of medical volunteers; (3) acquisition and management of 

medical equipment; 

(4) development of alternate care sites; and (5) identification of 

guidelines for altering triage, admission, and patient care. 

This study is based on a purposive sample of 5 States and 10 localities 

and presents a snapshot of these States’ and localities’ preparedness for 

an influenza pandemic as of late summer 2008. The study is based on a 

review of documentation from ASPR, CDC, and the selected States and 

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EXECUTIVE SUMMARY 

localities, as well as structured in-person interviews with key officials in 

each of the selected States and localities. 

FINDINGS 

All of the selected localities had established partnerships to 

prepare for a medical surge; however, the degree to which 

coordination occurred varied. As of late summer 2008, all 

10 localities had developed committees to help plan for a pandemic, as 

well as health care coalitions to coordinate the efforts of health care 

facilities. In addition, all localities had started to include hospitals in 

their emergency response planning. Although these partnerships 

helped to prepare for a medical surge, the degree to which coordination 

occurred varied among the 10 localities. 

Fewer than half of the selected localities had started to recruit 

medical volunteers, and none of the five States had implemented 

an electronic system to manage them. Four localities had started to 

recruit, register, and train medical volunteers. All four, however, had 

concerns about using volunteers. In addition, none of the five States 

had fully implemented an electronic system for managing medical 

volunteers. States were required by ASPR to have electronic systems to 

register medical volunteers and verify credentials by August 2009. 

All of the selected localities had acquired limited medical 

equipment for a pandemic, but only three of the five States had 

electronic systems to track beds and equipment. All 10 localities 

had acquired limited caches of medical equipment; however, many 

experienced difficulties with managing this equipment. In addition, 

only three of the five States had implemented electronic systems to 

track available hospital beds and medical equipment during an 

emergency. 

Most of the selected localities were in the early stages of planning 

for alternate care sites. Alternate care sites are preselected facilities, 

such as schools or convention centers, that have been identified for 

potential use during emergencies to help alleviate overcrowding in 

hospitals. Nine localities had either identified or were in the process of 

identifying alternate care sites to be used in a pandemic; however, few 

had signed formal agreements. None of the localities that were 

planning to use alternate care sites had plans that included the scope of 

care and how these sites would be managed, staffed, and supplied. 

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EXECUTIVE SUMMARY

Most of the selected localities had not identified guidelines for 

altering triage, admission, and patient care; many cited liability 

concerns. During a pandemic, health care professionals may need to 

alter how they provide medical care by allocating scarce resources in a 

manner that saves the greatest number of lives. Nine localities had not 

identified guidelines for altering triage, admission, and patient care 

during a pandemic. Seven of these localities noted that providers in 

their localities were concerned that they would be legally at risk if they 

were to alter their standards for triage, admission, or patient care, and 

all nine reported that they wanted additional State or Federal guidance. 

All of the selected localities conducted medical surge exercises; 

however, none consistently documented the lessons learned. 

Localities conducted between one and seven medical surge exercises 

over a 2-year period. Most of these exercises were discussion-based, 

rather than operations-based. Although localities are encouraged to 

document lessons learned during exercises through the creation of 

after-action reports and improvement plans, none consistently 

completed these documents for their exercises. In addition, the existing 

documentation that we reviewed showed that localities needed to make 

improvements within the five medical surge components. 

RECOMMENDATIONS 

Based on these findings, we recommend that ASPR, in collaboration 

with CDC: 

Work with States and localities to improve their efforts within each 

of the five components of medical surge that we reviewed. 

• ASPR should continue to emphasize the importance of coordination and 

involving a wide array of stakeholders in medical surge and pandemic 

planning. 

• ASPR should continue to emphasize the importance of recruiting, 

registering, and training medical volunteers for use in a pandemic. 

• ASPR should continue to emphasize the importance of managing 

medical equipment currently being stockpiled for a public health 

emergency, such as a pandemic. 

• ASPR should continue to emphasize the importance of planning for 

alternate care sites for use during a pandemic. 

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EXECUTIVE SUMMARY

• ASPR should emphasize the importance of identifying and adopting 

guidelines for altering triage, admission, and patient care during a 

pandemic. 

Ensure that States and localities consistently document the lessons 

learned from preparedness exercises that address medical surge. 

Given the importance of exercises in strengthening preparedness, ASPR, 

in collaboration with CDC, should ensure that States and localities 

consistently document the lessons learned from all medical surge exercises 

that require documentation. 

Address the issue of legal protections for medical professionals and 

volunteers who respond to public health emergencies, such as an 

influenza pandemic. ASPR should consider working with States to 

develop appropriate legal protections for medical professionals and 

volunteers who respond to public health emergencies and who may need to 

alter standards of care. ASPR should also consider the feasibility of 

Federal legislation in this area. 

Facilitate the sharing of information and emerging practices 

among States and localities. ASPR, in collaboration with CDC, 

should collect information on emerging practices from States and 

localities, as well as experts in the field, to further improve medical 

surge preparedness. ASPR should employ a variety of strategies to 

facilitate the sharing of this information and emerging practices 

among States and localities. 

Provide training and technical assistance to States and localities on 

key issues. ASPR, in collaboration with CDC, should address specific 

State and local challenges, such as identifying alternate care sites, 

managing medical equipment, and identifying guidelines for alternate 

standards of care. 

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

ASPR concurred with all five of our recommendations. CDC did not 

formally comment, but did provide technical comments. We made 

changes to the final report based on CDC’s technical comments, as 

appropriate. 

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Δ TABLE OF CONTENTS 

EXECUTIVE SUMMARY .....................................i

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 

FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 

 All of the selected localities had established partnerships to 

 prepare for a medical surge; however, the degree to which 

 coordination occurred varied . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 

 Fewer than half of the selected localities had started to recruit 

 medical volunteers, and none of the five States had implemented 

 an electronic system to manage them . . . . . . . . . . . . . . . . . . . . . . 13 

All of the selected localities had acquired limited medical 

equipment for a pandemic, but only three of the five States had 

electronic systems to track beds and equipment . . . . . . . . . . . . . . 15 

 Most of the selected localities were in the early stages of 

 planning for alternate care sites . . . . . . . . . . . . . . . . . . . . . . . . . . 17 

 Most of the selected localities had not identified guidelines for 

 altering triage, admission, and patient care; many cited liability 

 concerns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 

 All of the selected localities conducted medical surge exercises; 

 however, none consistently documented the lessons learned . . . . 20 

RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 

 Agency Comments and Office of Inspector General Response . . . 27 

APPENDIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 

 A: Selected States and Localities. . . . . . . . . . . . . . . . . . . . . . . . . . 28 

 B: Agency Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 

ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Δ TABLE OF CONT INTRODUCTION ENTS 

OBJECTIVE 

To determine the extent to which selected States and localities have: 

1. prepared for a medical surge in response to an influenza pandemic 

and 

2. conducted and documented exercises that test their medical surge 

preparedness for an influenza pandemic. 

BACKGROUND 

An influenza pandemic is a global outbreak of a highly infectious 

influenza virus that can cause serious illness in humans.1 HHS 

estimates that even a mild influenza pandemic could cause between 

2 and 7.4 million deaths worldwide.2 In June 2009, after human cases 

of a novel H1N1 influenza were identified in the United States and 

internationally, the World Health Organization raised its influenza 

pandemic alert level to Phase 6, indicating that a pandemic is 

underway.3 Although scientists cannot predict this pandemic’s severity, 

it has highlighted the importance of ongoing emergency preparedness 

efforts. 

In February 2008, the Assistant Secretary for Preparedness and 

Response (ASPR) within HHS asked the Office of Inspector General 

(OIG) to evaluate State and local preparedness for influenza pandemic, 

particularly with regard to medical surge and vaccine and antiviral 

drug distribution and dispensing. 

This evaluation focuses on the extent to which selected States and 

localities have prepared for a medical surge during a pandemic. 

Medical surge is a rapid expansion of the health care system in response 

to an event that requires resources—such as hospital beds, medical 

equipment, and personnel—that exceed what the normal medical 

1 Department of Health and Human Services (HHS), “Flu Terms Defined.” Available 

online at http://www.pandemicflu.gov. Accessed on February 17, 2009. 

2 HHS, “Why are pandemics such dreaded events?” Available online at 

http://www.pandemicflu.gov/faq/pandemicinfluenza/1108.html. Accessed on February 17, 

2009. 

3 World Health Organization, “World now at the start of 2009 influenza pandemic.” 

Available online at http://www.who.int/mediacentre/news/statements/2009/h1n1_pandemic

_phase6_20090611/en/index.html. Accessed on August 10, 2009. 

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INTRODUCTION 

infrastructure can provide.4 A second OIG evaluation focuses on the 

extent to which selected localities have prepared for vaccine and 

antiviral drug distribution and dispensing during a pandemic.5 In 

addition, OIG is auditing three States to determine whether certain 

expenditures used to prepare for an influenza pandemic complied with 

Federal requirements.6

HHS Support of State and Local Preparedness Efforts 

2 

andemic. 

Since 2002, HHS has provided more than $8 billion for programs to 

enhance their emergency preparedness for large-scale public health 

emergencies.7 HHS has distributed this funding primarily through 

cooperative agreements under two programs—ASPR’s HPP8 and the 

Centers for Disease Control and Prevention’s (CDC) PHEP.9 In 

addition to providing general emergency preparedness funds, HHS has 

provided $600 million in supplemental funding specifically for 

improving preparedness for an influenza p

4 The CNA Corporation, “Medical Surge Capacity and Capability: A Management 

System for Integrating Medical and Health Resources During Large-Scale Emergencies,” 

August 2004, p. I 5. 

5 OIG, “Local Pandemic Influenza Preparedness: Vaccine and Antiviral Drug 

Distribution and Dispensing,” OEI-04-08-00260. 

6 OIG, “Review of Vermont’s Pandemic Influenza Expenditures for the Period August 31, 

2005, Through June 30, 2008,” A-01-08-01500, June 25, 2009; “Review of Washington 

State's Pandemic Influenza Expenditures for the Period August 31, 2005, Through June 30, 

2008,” A-09-08-01006, August 21, 2009. OIG is also auditing pandemic influenza 

expenditures in Georgia. 

7 HHS, “HHS Announces $896.7 Million in Funding to States for Public Health 

Preparedness and Emergency Response.” Available online at 

http://www.hhs.gov/news/press/2007pres/07/pr20070717c.html. HHS also provided an 

additional $1 billion in Public Health Emergency Preparedness Program (PHEP) and 

Hospital Preparedness Program (HPP) funds in 2008. See HHS, “HHS Provides More Than 

$1 Billion to Improve All Hazards Public Health.” Available online at 

http://www.hhs.gov/news/press/2008pres/06/20080603a.html. Accessed on March 6, 2009. 

8 The administration of HPP was transferred to ASPR from the Health Resources and 

Services Administration (HRSA) in December 2006. (See 42 U.S.C. § 300hh-10, as added by 

P.L. No. 109-417, Title I, § 102(a)(3)). Activities under HPP are currently authorized by 

42 U.S.C. §§ 247d-3a and 247d-3b. 

9 CDC has cited various authorities for PHEP and PHEP supplemental funding. CDC is 

currently relying on section 319C-1 of the Public Health Service Act (42 U.S.C. § 247d-3a) 

for all of these grant awards. 

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INTRODUCTION 

The Secretary of HHS has been designated the lead official for all 

Federal public health and medical response in the event of a public 

health emergency.10 ASPR is the primary agency within HHS 

responsible for improving medical surge preparedness. ASPR provides 

funding and guidance through HPP to improve the response of the 

health care system during public heath emergencies.11 CDC generally 

plays a supporting role in medical surge preparedness by focusing on 

improving the response of the public health system during an 

emergency, such as an influenza pandemic. 

The focus of both HPP and PHEP funding is to build the capability of 

the health care and public health systems to minimize the number of 

deaths, long term disabilities, injuries, and hospitalizations from events, 

such as pandemics.12 In general, HPP and PHEP guidance require that 

States prioritize preparedness activities and outline how they will spend 

the funds.13 The guidance generally allows States to specify in their 

grant applications the activities that they intend to complete to improve 

their preparedness.14 As these programs have evolved, the guidance 

has often emphasized varying program priorities. In addition, although 

Federal funding and guidance are provided to States, many of the 

activities needed to prepare for an influenza pandemic are carried out 

by localities. 

3 

10 This authority was established with the passage of the 2006 Pandemic and 

All-Hazards Preparedness Act, P.L. No. 109-417, § 201, 42 U.S.C. § 247d. 

11 Funding for both HPP and PHEP was provided to the 50 States; Washington, DC; 

five territories (Puerto Rico, the Virgin Islands, American Samoa, Commonwealth of the 

northern Mariana Islands, and Guam); the Pacific Freely Associated States (Republic of the 

Marshall Islands, Republic of Palau, and the Federated States of Micronesia); and the 

localities of Chicago, Los Angeles County, and New York City. For the purposes of this 

report, we refer to these entities as States. 

12 HRSA, National Bioterrorism Hospital Preparedness Program (hereinafter referred to 

as HPP Fiscal Year (FY) 06 guidance), FY 2006, p.5; CDC, Pandemic Influenza Guidance 

Supplement to the 2006 Public Health Emergency Preparedness Cooperative Agreement 

Phase II (hereinafter referred to as PHEP Phase II guidance), p. 5. 

13 HPP FY 06 guidance, pp. 29-30; ASPR, Announcement of Availability of Funds for the 

Hospital Preparedness Program, Pandemic Influenza Supplement for Medical Surge 

Capacity and Capability, p. 2; PHEP Phase II guidance, p. 9. 

14 Ibid. 

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Medical Surge in Response to a Pandemic 

4 

five 

EP 

 If a severe pandemic occurs, it will affect much of the country at the 

same time, so medical resources—such as hospital beds, medical 

equipment, and personnel—will likely be scarce.15 The ability to 

rapidly respond to this increased demand for medical resources is often 

referred to as medical surge. This study focuses on the following 

key components of medical surge that were identified in HPP and PH

guidance: (1) coordination among stakeholders; (2) recruitment and 

management of medical volunteers; (3) acquisition and management of 

medical equipment; (4) identification of alternate care sites; and (5) 

identification of guidelines for altering triage, admission, and patient 

care. 

Coordination among stakeholders: HPP and PHEP guidance 

consistently emphasize that medical surge preparedness requires 

coordination among a variety of public and private stakeholders, 

including hospitals and other health care facilities, public health 

departments, and emergency management departments. HPP and 

PHEP guidance also encourage States and localities to establish 

pandemic influenza coordinating committees and health care coalitions 

to help plan for a pandemic. Additionally, these documents encourage 

localities to integrate the efforts of private health care facilities with 

those of the local departments of public safety, emergency management, 

and public health.16

Recruitment and management of medical volunteers: In the event of a 

pandemic, States and localities may be forced to rely on large numbers of 

medical volunteers. HPP guidance encourages States and localities to 

recruit, register, and train medical volunteers prior to a pandemic as part 

of the Emergency System for Advance Registration of Volunteer Health 

Professionals (ESAR-VHP) program. Additionally, the guidance 17

15 Agency for Healthcare Research and Quality (AHRQ), AHRQ Publication No. 07-0001, 

“Mass Medical Care with Scarce Resources: A Community Planning Guide (2007).” 

Available online at http://www.ahrq.gov/research/mce/mceguide.pdf. Accessed on 

April 23, 2008. 

16 ASPR, Announcement of Availability of Funds for the Hospital Preparedness Program, 

Pandemic Influenza Supplemental for Medical Surge Capacity and Capability for Budget 

Period October 31, 2007–October 31, 2008, p. 4 (hereinafter referred to as HPP FY 07 

guidance); PHEP Phase II guidance, p. 3. 

17 Note that HPP guidance references additional guidance in the following document: 

HRSA, “ESAR-VHP Program Interim Technical and Policy Guidelines, Standards, and 

Definitions,” Version 2, June 2005. ASPR plans to release Version 3 of this guidance in 

2009. 

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5 

gust 2009.18 

required States to develop electronic systems to register medical 

volunteers and verify credentials by Au

Acquisition and management of medical equipment: During a severe 

pandemic, medical equipment will likely be scarce. Both HPP and 

PHEP supplemental funding can be used to purchase medical 

equipment at the State and local levels. Localities are generally 

responsible for storing, maintaining, and transporting this medical 

equipment. In addition, HPP requires States to maintain a system that 

enables them to report to HHS the number of available hospital beds.19 

It also encourages States to make these systems electronic; however, 

States have the option of manually entering the data they receive from 

hospitals into an HHS Web site. In addition, States are encouraged to 

establish interoperable inventory-tracking systems that assist with the 

management of medical equipment during an emergency.20

Development of alternate care sites: Alternate care sites are preselected 

facilities—such as schools or convention centers—that have been identified 

for potential use during emergencies to help alleviate overcrowding in 

hospitals. They can also be mobile alternate care sites that are 

preequipped with tents and beds and can be set up quickly in various 

locations. HPP and PHEP guidance encourage hospitals, in conjunction 

with other community partners, to identify appropriate locations for 

alternate care sites.21 Before being able to use these sites, localities need 

to engage in a significant amount of planning. Such planning generally 

consists of determining the scope of care that will be provided at the site in 

an emergency and establishing how the site will be managed, staffed, and 

supplied. 

18 HPP FY 07 guidance pp. 2-3; 1-year extension provided for in ASPR, Announcement of 

Availability of Funds for HPP, FY 08, p. 12. 

19 HPP FY 07 guidance. States were required to have such reporting capabilities—

referred to as the standards for Hospital Available Beds for Emergencies and Disasters—by 

August 8, 2008. 

20 Note that HPP guidance requires States to be compliant with the National Incident 

Management System, which encourages States to have interoperable systems in place to 

track equipment. In the future, these systems will be required for States. See Federal 

Emergency Management Agency, IS-700.a National Incident Management System, An 

Introduction, I-700.a, Unit 5. Available online at: 

http://training.fema.gov/EMIWeb/IS/is700alst.asp. Accessed on May 21, 2009. 

21 PHEP Phase II guidance, p. 32. The guidance also encourages States to use a tool 

developed by AHRQ to help identify facilities that can be used as alternate care sites. 

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Identification of guidelines for altering triage, admission, and patient care: 

A severe pandemic will likely require changes to how medical care is 

provided. Physicians and other health care professionals may need to 

alter triage, admission, and patient care. Such alterations are referred to 

as altered standards of care, which generally require allocating scarce 

equipment, supplies, and personnel in a manner that saves the greatest 

number of lives, as opposed to the traditional focus of treating the sickest 

or most injured patients first.22 In 2004, HHS developed 

recommendations to States and localities for how to alter patient care, 

emphasizing that such efforts should involve unified local and regi

planning.

onal 

ns 

e that 

c.24 

23 Specifically, localities are encouraged to identify and adopt 

guidelines for altering triage, admission, and patient care to ensure that

all hospitals and other health care providers are making uniform decisio

during a pandemic. In addition, the American Health Lawyers Association 

(AHLA), in cooperation with CDC and OIG, developed a checklist that 

encourages health care providers to develop altered standards of car

may become necessary in a pandemi

Exercises To Address Medical Surge

States and localities conduct exercises to test and improve their 

medical surge preparedness. HPP and PHEP guidance require States 

to conduct medical surge exercises.25 Localities may participate in 

State exercises or conduct their own exercises. 

Exercises generally fall into two categories. Discussion-based 

exercises enable participants to become familiar with current plans, 

policies, and procedures. In contrast, operations-based exercises 

enable participants to execute plans, policies, and procedures in order 

to clarify roles and responsibilities and identify resource gaps.26 

PHEP guidance suggests using discussion-based exercises to identify 

22 AHRQ, “Altered Standards of Care in Mass Casualty Events,” April 2005. Available 

online at http://www.ahrq.gov/research/altstand/altstand1.htm. Accessed on March 6, 2009. 

23 Ibid. 

24 This document also provides a comprehensive list of potential legal issues that health 

care providers may face during an influenza pandemic. See AHLA, “Community Pan-Flu 

Preparedness: A Checklist of Key Legal Issues for Healthcare Providers,” 2008. Available 

online at http://www.healthlawyers.org/panfluchecklist. Accessed on May 13, 2009. 

25 HPP guidance required that States conduct at least one medical surge exercise by 

August 2008. PHEP required States to conduct at least one medical surge exercise by 

August 2007. HPP FY 07 guidance, pp. 15–17; PHEP Phase II guidance, pp. 10–11. 

26 Homeland Security Exercise and Evaluation Program (HSEEP). Available online at 

https://hseep.dhs.gov/pages/1001_HSEEP7.aspx. Accessed on March 6, 2009. 

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INTRODUCTION 

and address gaps in preparedness plans before conducting more 

resource-intensive operations-based exercises.27

HPP and PHEP guidance also encourage States to conduct exercises 

in accordance with the HSEEP program.28 HSEEP requires 

participants to create an after-action report and an improvement plan 

for each exercise. After-action reports include the exercise objectives, 

participant observations, and general recommendations. 

Improvement plans incorporate the lessons learned during the 

exercise and include specific corrective actions, the responsible 

parties, and dates for their completion. 

Related Work 

In 2009, the Center for Biosecurity of the University of Pittsburgh 

Medical Center, under contract with ASPR, released a report on the 

impact of HPP on hospital preparedness from 2002 to 2007.29 It found 

that disaster preparedness of individual hospitals had improved 

significantly throughout the country since the start of HPP. 

Specifically, it found that the emergence of health care coalitions 

created a foundation for health care preparedness, but that health care 

planning for catastrophic emergencies was still in its early stages, 

particularly with regard to altering standards of care. 

In 2008, the Government Accountability Office (GAO) released a report 

that found that selected States and localities had developed pandemic 

influenza plans.30 These States and localities had also conducted or 

participated in at least one exercise to test their plans. Further, GAO 

found that according to HHS’s review of these plans, States had major 

gaps in many areas, including medical surge. 

In 2008, GAO released another report that found that the Federal 

Government had provided funding, written guidance, and other 

assistance, such as holding conferences, to help States prepare for 

7 

27 PHEP Phase II guidance, p. 6. 

28 HPP FY 07 guidance, pp. 16–17; PHEP Phase II guidance, p. 4. Beginning in August 

2008, HSEEP compliance was required for all exercises associated with HPP or PHEP 

funding. 

29 Center for Biosecurity of the University of Pittsburgh Medical Center, “Hospitals 

Rising to the Challenge: The First Five Years of the U.S. Hospital Preparedness Program 

and Priorities Going Forward,” March 2009. 

30 GAO, “Influenza Pandemic: Federal Agencies Should Continue to Assist States to 

Address Gaps in Pandemic Planning,” GAO-08-539, June 2008. 

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INTRODUCTION 

medical surge in a mass casualty event. 31 GAO reported that the 

20 States it reviewed were planning for medical surge at the State 

level and had made efforts in increasing hospital capacity, identifying 

alternate care sites, and registering medical volunteers, but that 

fewer were planning for altered standards of care. GAO further noted 

that these 20 States continued to face challenges in preparing for 

medical surge in a mass casualty event. 

METHODOLOGY 

This review determines how selected States and localities have prepared 

for medical surge in response to an influenza pandemic and the extent to 

which they have conducted and documented exercises that test their 

preparedness. It presents a snapshot of selected States’ and localities’ 

preparedness for an influenza pandemic as of late summer 2008. This 

review is based on data from two sources: (1) a review of documentation 

from ASPR, CDC, and the selected States and localities; and (2) structured 

in-person interviews with key officials in each of the selected States and 

localities. 

Selection of Sampled States and Localities 

We selected a purposive sample of five States based on the following 

factors: health department structure, population density, geographic 

distribution, and input from ASPR and CDC. We selected one State 

included in related OIG studies and eliminated other States included in 

recent GAO work related to this evaluation. The States we selected 

were Maine, Missouri, South Dakota, Virginia, and Washington. In 

each State, we selected the largest Metropolitan Statistical Area (MSA) 

and then selected the most populated city within that MSA. We also 

selected one low- to medium-sized city in each State. We did not select 

localities in counties that were adjacent to each other to ensure that 

localities were in different regional planning areas. See Appendix A for 

a list of the selected localities. 

Data Collection 

Selection of medical surge components: We selected the following five 

key components of medical surge based on a review of HPP and PHEP 

guidance and input from officials at CDC and ASPR: (1) coordination 

31 GAO, “Emergency Preparedness: States Are Planning for Medical Surge, but Could 

Benefit from Shared Guidance for Allocating Scarce Medical Resources,” GAO-08-668, 

June 2008. 

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INTRODUCTION 

among stakeholders; (2) recruitment and management of medical 

volunteers; (3) acquisition and management of medical equipment; 

(4) identification of alternate care sites; and (5) identification of 

guidelines for altering triage, admission, and patient care. 

State and local documentation: To determine how selected States and 

localities have prepared for a medical surge, we first requested 

documentation from ASPR and CDC. Specifically, we requested HPP, 

HPP supplemental, and PHEP supplemental applications and progress 

reports that covered the time between 2006 and 2008 for each of the five 

selected States. We also requested any assessments that ASPR and CDC 

conducted of these documents. 

In addition, from each selected State and locality, we requested all 

available documentation related to the five components of medical surge 

that we reviewed. These documents included States’ and localities’ 

pandemic influenza plans and various other documents, such as committee 

meeting notes, memoranda of understanding, and descriptions of 

equipment. We also requested all available documentation about the 

exercises that these States and localities conducted from August 2006 to 

August 2008 that were related to these five components of medical surge, 

including any after-action reports and improvement plans.32 

Structured interviews with State and local officials: We conducted 

structured in-person interviews with officials responsible for coordinating 

medical surge in each of the 5 States and 10 localities. At the State level, 

these officials typically included State HPP and PHEP coordinators and 

State emergency preparedness exercise coordinators. At the local level, we 

determined how each State distributed its HPP and PHEP funds to its 

localities and identified the key local officials responsible for coordinating 

medical surge activities. These officials typically included representatives 

involved in pandemic planning activities as well as representatives from 

local public health departments and hospitals. In a few localities, 

representatives from emergency management services were also present.

We conducted the interviews between July and September 2008. 

32 For the purpose of our review, we included exercises that localities either conducted or 

participated in (including exercises that the State conducted in which the selected localities 

participated). We did not include routine drills because they are limited to an exercise of a 

single entity and function. We also did not include workshops as they are generally focused 

on achieving a particular objective, such as developing a new draft plan or policy. 

 O E I - 0 2 - 0 8 - 0 0 2 1 0 S TATE AND L OCAL PANDEMIC I NFLUENZA P REPAREDNESS : MEDICAL S URGE 9 
INTRODUCTION 

During our interviews, we asked State and local officials about their 

preparedness activities for medical surge and about the exercises they 

had conducted within the five components that we reviewed. Our 

discussions with State officials focused on the State’s role in each of the 

five components as well as in conducting exercises. Our discussions 

with local officials focused on the localities’ progress and challenges 

within each of the five components, as well as the localities’ exercise 

programs. Throughout the report, we use the term “States” to refer to 

the State officials that we interviewed and “localities” to refer to the 

local and regional officials that we interviewed. 

Data Analysis 

To determine how the selected States and localities have prepared for a 

medical surge, we relied on both the State and local documentation we 

collected, as well as the responses from the structured interviews with 

State and local officials. We compared the documentation to the 

information gathered during our structured interviews and looked for 

consistency among the sources of data. We also asked for additional 

documentation, when appropriate, to validate certain responses about 

States’ and localities’ preparedness activities. For example, we 

reviewed memoranda of understanding or other documentation to verify 

that localities had formal agreements in place that would allow them to 

set up alternate care sites. We also reviewed meeting notes and agenda 

to verify that localities coordinated with certain entities. In addition, 

we compared the responses of the State officials to those of the local 

officials. We also looked for corroboration among the various officials 

present at each interview. To determine the extent to which States and 

localities have conducted and documented exercises that test their 

medical surge preparedness, we relied primarily on the documentation 

we collected from the States and localities, including any after-action 

reports and improvement plans. 

Limitations 

This study is based on a purposive sample of five States and two 

localities within each of these States. The findings cannot be projected 

to other States and localities. In addition, the five components of 

medical surge that we reviewed do not encompass all aspects of medical 

surge preparedness. For example, other aspects of medical surge may 

include preparedness activities designed to improve hospital 

evacuations and fatality management. 

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INTRODUCTION 

Standards 

This study was conducted in accordance with the “Quality Standards for 

Inspections” approved by the Council of the Inspectors General on 

Integrity and Efficiency. 

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Δ FINDINGS

HPP and PHEP guidance 

emphasize that medical surge 

preparedness necessitates 

coordination among a variety of 

public and private stakeholders. 

These documents also encourage States and localities to establish 

pandemic influenza coordinating committees and health care coalitions 

to help plan for a pandemic. Additionally, the documents encourage 

localities to integrate the efforts of health care facilities with the efforts 

of agencies for public safety, emergency management, and public health. 

All of the selected localities had established 

partnerships to prepare for a medical surge; 

however, the degree to which coordination 

occurred varied 

All 10 localities had developed committees to help plan for a pandemic 

As of late summer 2008, all 10 localities we reviewed had established 

committees to help plan for an influenza pandemic. These committees 

generally included representation from health care, public health, 

emergency management, public safety, local schools, and private 

industry. These committees typically were responsible for developing 

the localities’ pandemic influenza response plans. They also commonly 

discussed issues important to pandemic planning, such as the use of 

volunteer health care personnel and alternate care sites, as well as how 

best to use funds from State and Federal agencies to prepare for a 

pandemic. 

Although all 10 localities had established such committees, the degree to 

which coordination occurred varied among the localities. In some 

localities, the committees were actively engaged and met monthly, whereas 

in other localities they met less frequently. In addition, the degree to 

which the local health departments participated in these preparedness 

committees also varied among localities. Many localities reported 

challenges with keeping necessary partners engaged in pandemic 

planning. As a few noted, planning was often fragmented because there 

were multiple agencies and different funding streams involved. 

All 10 localities had developed health care coalitions to coordinate the 

efforts of health care facilities 

All 10 localities had developed health care coalitions to coordinate the 

preparedness efforts of health care facilities and providers and to 

develop plans for medical emergencies, such as a pandemic. 

Localities most commonly reported that the most active participants 

in their coalitions were local and regional hospitals. However, some 

localities reported that keeping hospitals engaged in the coalitions’ 

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FINDINGS 

activities was difficult, as hospitals were often strained by increasing 

preparedness requirements, decreasing funding, and the everyday 

pressures to stay in business. 

The extent to which localities had started to include other types of health 

care providers in their coalitions differed. Many localities were in the 

early stages or had not attempted to include nonhospital providers at all. 

For example, only 3 of the 10 localities had coalitions that involved home 

health care agencies, 5 localities had coalitions that involved nursing 

homes, and 5 localities had coalitions that involved local heath care clinics. 

In addition, several localities emphasized that their goal in working with 

these other health care providers was mainly educational. 

All 10 localities had started to include hospitals in their emergency 

response planning 

All 10 localities had started to include hospitals in their emergency 

response planning. Until recently, hospitals were not typically part of 

localities’ emergency response planning. However, several localities noted 

that the relationships between hospitals and emergency management, 

public safety, and public health officials—although relatively new—were 

critically important to the localities’ pandemic planning response. As one 

hospital official stated, “we need to play a bigger role in emergency 

planning, especially if we are facing something like a pandemic.” 

At the same time, the degree to which hospitals were included in 

emergency response planning varied. A few localities had well-established 

systems for sharing information between emergency management agencies 

and hospitals. Other localities were just beginning to develop these 

relationships, and several hospitals reported that they had not been fully 

integrated into their localities’ emergency response planning. 

Medical staff will likely be scarce 

during a severe pandemic, and 

localities may need to rely on 

medical volunteers to help respond 

to the increased demands upon the 

medical infrastructure. To prepare for this, HPP guidance encourages 

States and localities to recruit, register, and train medical volunteers as 

part of the ESAR-VHP program. HPP guidance also required States to 

develop electronic systems to register medical volunteers and verify 

credentials by August 2009. 

Fewer than half of the selected localities had 

started to recruit medical volunteers, and none 

of the five States had implemented an 

electronic system to manage them 

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FINDINGS 

Four localities had started to recruit, register, and train medical volunteers 

As of late summer 2008, 4 of the 10 localities had started to recruit, 

register, and train medical volunteers to be used in a pandemic. These 

localities planned to use their volunteers primarily in alternate care 

sites and, to a lesser degree, in hospitals. Two of the remaining 

localities were in the early stages of developing policies and procedures 

to recruit volunteers, whereas four others had no plans to recruit or 

train volunteers, as they intended to use volunteers from other 

organizations, such as the Red Cross, or rely on spontaneous volunteers. 

The four localities that had started to recruit volunteers reported 

registering between 38 and 200 volunteers each. To recruit volunteers, 

they typically used media advertisements and in-person presentations 

at health fairs and medical association meetings. They often targeted 

specific groups, such as retired medical professionals; school nurses; 

medical and nursing school students; and medical societies. To register 

their volunteers, all four localities had some type of background check 

that typically involved interviews, fingerprinting, and the verification of 

medical licenses. All four localities also offered training to volunteers in 

areas such as first aid techniques. In addition, two of these localities 

used their volunteers on a routine basis, such as helping to staff 

seasonal influenza clinics. 

The four localities had several factors in common that may have helped 

them develop their volunteer programs. These factors included having 

a paid volunteer coordinator, using an existing Federal volunteer 

program called the Medical Reserve Corps,33 and having multiple 

sources of funding to help support their volunteer programs. 

At the same time, these four localities expressed a number of concerns 

about using volunteers. They were concerned primarily that their 

volunteers would not show up during a pandemic because of competing 

work or other volunteer commitments or because of fears that the 

volunteers would not be legally protected during a pandemic. They also 

noted that volunteers may not have worked in a clinical setting 

recently, may not have current medical licenses, or may have physical 

limitations, thereby limiting the role that the volunteers could play 

14 

33 The Medical Reserve Corps in the Office of the Surgeon General is a nationwide 

program that uses medical and public health professionals in a volunteer capacity to 

improve the health and safety of communities. Medical Reserve Corps are local units that 

strengthen the public health infrastructure of their communities. 

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FINDINGS 

during a pandemic. Other concerns focused on the amount of resources 

needed to maintain a successful volunteer program. 

None of the five States had fully implemented an electronic system for 

managing medical volunteers 

As of late summer 2008, none of the five States had fully implemented 

an electronic system to manage volunteers. As noted earlier, HPP 

required States to have electronic systems for managing medical 

volunteers by August 2009. Four of the five States reported that they 

were in the process of selecting system software, developing their 

systems, or writing policies for using their systems. The remaining 

State reported that its system was not fully operational in that it was 

still developing the ability to verify the credentials of volunteers. 

Even though these systems were not fully operational, a number of the 

localities expressed concerns about using their States’ systems. Two 

localities that had their own systems for registering and credentialing 

volunteers were reluctant to transition to the new State system. In 

addition, three localities expressed concerns that their States may use 

the system to deploy local volunteers without alerting the localities. 

During a severe pandemic, 

the availability of medical 

equipment may be 

insufficient. To address 

this, both PHEP and HPP 

provide States with 

funding that can be used to purchase medical equipment at the State 

and local levels. Localities are generally responsible for storing, 

maintaining, and transporting this medical equipment. In addition, 

HPP requires States to maintain systems that enable them to report to 

HHS the number of available hospital beds and encourages States to 

make these systems electronic. States are also encouraged to establish 

inventory systems to track medical equipment during an emergency. 

All of the selected localities had acquired limited 

medical equipment for a pandemic, but only 

three of the five States had electronic systems 

to track beds and equipment 

All 10 localities had acquired limited caches of medical equipment; however, 

many experienced difficulties with managing this equipment 

As of late summer 2008, all 10 localities had acquired limited medical 

equipment to be used during a pandemic. These caches included a variety 

of equipment, such as ventilators; portable beds; and personal protective 

equipment, such as masks, respirators, and gloves. 

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FINDINGS 

The localities used different approaches for storing this equipment. Two 

localities distributed all of their equipment to local hospitals, whereas the 

remaining eight localities retained some equipment in regional caches and 

distributed the remainder to hospitals. The regional caches typically 

consisted of equipment stored in trailers or public health departments. 

The equipment stored in hospitals could be used in nonemergency 

situations; however, hospitals were generally responsible for maintaining 

and replacing the equipment so that it could be redistributed in an 

emergency if needed. 

Almost all of the localities reported having difficulties with managing 

the equipment that they had acquired for a pandemic. Many noted that 

local hospitals and health departments often did not have sufficient 

storage space. Some localities also reported problems with maintaining 

the equipment, indicating, for example, that they were sometimes 

unsure of whether hospitals were replacing items that had expired.34 

Others mentioned difficulties with trying to standardize the medical 

equipment, such as ventilators, in their caches. As one official noted, 

this is particularly important because standardization makes it easier 

to share equipment and it simplifies training. Finally, a few localities 

noted that there are logistical challenges with moving equipment from 

one location to another. 

Many localities were also concerned that existing caches would be rapidly 

depleted during a pandemic. They anticipated problems with obtaining 

equipment through normal channels during a pandemic and questioned 

whether vendors would be able to honor their contracts with an influx of 

competing orders to fill. A few officials noted that supply chains may be 

disrupted during a pandemic, especially if the supplies are shipped from 

overseas or from another State. 

Three States had implemented electronic systems to track available hospital 

beds and medical equipment during an emergency 

Although all five States were able to meet the requirement to report 

available beds to HHS, only three States had implemented electronic 

systems to track available hospital beds during an emergency. In 

addition to electronically tracking available beds, these systems were 

also able to track various types of medical equipment, such as 

16 

34 Certain medical materials (e.g., personal protective equipment) are imprinted with an 

expiration date. Beyond this date, the manufacturer does not guarantee the sterility, 

safety, or stability of the item. 

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FINDINGS 

respirators or masks. The States noted that these systems simplified 

the process of collecting data from hospitals. In addition, these systems 

enabled States to quickly disseminate information to hospitals and 

localities. The remaining two States were in the process of developing 

such systems and noted that their current methods for collecting data 

were cumbersome. 

At the same time, most of the localities in the three States that had 

implemented electronic tracking systems reported difficulties with using 

these systems. They noted that their State systems were not compatible 

with other systems used during an emergency. For example, one 

locality near a State border had to input the same data into two States’ 

systems. Others mentioned incompatibilities with the systems used by 

local emergency management agencies. In addition, two localities were 

concerned about the reliability of the data. As one noted, its State 

system may not be kept up-to-date during an emergency because 

overburdened hospital staff might not reliably enter information into 

the system. 

Most of the selected localities were in the early 

stages of planning for alternate care sites 

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Localities may need to use alternate 

care sites to increase their medical 

surge capacity in a pandemic. Before 

being able to use alternate care sites, localities need to engage in a 

significant amount of planning. Such planning generally consists of 

identifying an appropriate location for the site; determining the scope of 

care that the site will provide in an emergency; and establishing how 

the site will be managed, staffed, and supplied. 

Nine localities had either identified or were in the process of identifying 

alternate care sites to be used in a pandemic; however, few had signed 

formal agreements 

As of late summer 2008, three localities had identified locations to be 

used as alternate care sites. Each of the three localities had identified 

between 3 and 11 sites that could be used as alternate care sites during 

a pandemic. The sites typically included buildings such as schools, 

churches, and convention centers. These localities had either signed or 

were in the process of signing formal agreements with the facility 

owners. In addition, one of these localities planned to use 

preequipped, mobile trailers that had been purchased by the State to 

supplement its alternate care sites during a pandemic. 
FINDINGS 

Six other localities were in the process of deciding which facilities to use 

for their alternate care sites. The remaining locality reported that it did 

not plan to use alternate care sites at all because it was concerned that 

it would not be able to staff these sites. Instead, its plan was for the 

hospitals in the area to take in as many patients as possible during a 

pandemic. 

None of the localities that were planning to use alternate care sites had 

plans that included the scope of care and how these sites would be 

managed, staffed, and supplied 

Of the nine localities that intended to use alternate care sites, a few 

addressed some of these components, but none addressed all of them. 

Scope of care. Only one locality that intended to use alternate care sites 

had defined the scope of care that would be provided. This locality 

planned to provide triage and care for only “minor problems” at the 

alternate care sites. The other eight localities were still considering 

various alternatives. In general, they explained that they would most 

likely provide triage, treatment, or both at their sites to help alleviate 

overcrowding in hospitals. Possible treatments ranged from lower 

levels of care, such as first aid, to more intensive care or palliative care. 

Managing alternate care sites. Three of the localities that intended to 

use alternate care sites had determined who would manage patient care 

at their sites. These localities had arranged for the health department, 

hospitals, regional coordinating entities, or a combination of these 

entities to manage their sites. 

The other six localities were less specific about who would be 

responsible for managing patient care at the site. One official reported 

that it is often challenging to find the appropriate people to manage an 

alternate care site; public health officials often did not have the 

specialized knowledge to manage and operate the sites, but private 

health care facilities (such as hospitals) often did not have the 

motivation. As several officials explained, hospitals often did not want 

to participate in managing alternate care sites because of liability 

concerns, as well as staffing and reimbursement concerns. 

Staffing alternate care sites. Only one locality had determined who 

would staff its alternate care sites. This locality planned to use medical 

volunteers that it had already recruited and trained. Six other localities 

that intended to use alternate care sites were still in the beginning 

stages of planning and were considering recruiting volunteers from 

groups such as the Red Cross, home health agency staff, health care 

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FINDINGS 

clinic staff, and medical school students. The remaining two localities 

said that they would primarily rely on hospital staff. 

Supplying alternate care sites. Four of the localities that intended to 

use alternate care sites said they had acquired some of the supplies 

needed for the sites. These localities were planning to use the medical 

equipment from either a regional cache or a mobile trailer stocked with 

medical equipment. In contrast, the remaining localities had not yet 

obtained supplies for the alternate care sites. These localities were 

either planning to order the equipment during a pandemic or were in 

the process of trying to acquire equipment for the sites. 

During a pandemic, guidelines 

governing triage, admission, and 

patient care may need to be 

altered to save as many lives as 

possible. To address this, 

localities may identify and adopt a standard set of guidelines for 

altering triage, admission, and patient care. Such an approach would 

ensure that all hospitals and other health care providers in the locality 

or region were making uniform decisions during a pandemic. 

Most of the selected localities had not identified 

guidelines for altering triage, admission, and 

patient care; many cited liability concerns 

Nine localities had not identified guidelines for altering triage, admission, 

and patient care during a pandemic 

As of late summer 2008, only one locality had identified a standard set 

of guidelines for altering triage, admission, and patient care during a 

pandemic. This locality was in the process of encouraging hospitals to 

adopt these guidelines to ensure that care was provided in a consistent 

manner. The guidelines that this locality identified were developed in 

Canada after the Severe Acute Respiratory Syndrome outbreak. These 

guidelines provide direction for how to alter patient care during a 

pandemic. They also assist health care providers with determining 

whether a patient should be admitted to a hospital for treatment or 

offered other options, such as palliative care. In particular, the 

guidelines provide hospitals with a scoring method based on specific 

characteristics of patients to use for triaging and for making decisions 

about how to equitably allocate limited resources, such as ventilators. 

Several localities highlighted the importance of coordinating the 

approaches of all hospitals and other health care providers in the 

region. As one hospital official noted, the lack of coordination between 

admission protocols could be devastating for a local hospital. For 

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FINDINGS 

example, if neighboring hospitals rely on different protocols for 

admission and patient care, one hospital could become inundated with 

patients denied care at the neighboring hospital. 

Localities commonly cited concerns about liability and a lack of State or 

Federal guidance 

The nine localities that had not identified a standard set of guidelines 

gave several reasons for their reluctance. Seven localities noted that 

providers in their localities were concerned that they would be legally at 

risk if they had to alter their triage, admission, or patient care. As one 

locality noted, “Our hospitals will functionally be practicing battlefield 

medicine. I don’t think providers are prepared to deal with this, and we 

haven’t even begun to deal with all the legal questions that will arise 

from practicing this type of medicine.” A few localities noted that 

instituting a uniform set of guidelines would minimize the legal risk to 

providers. 

The nine localities also reported that they wanted additional State or 

Federal guidance before attempting to institute uniform guidelines in 

their localities. Localities were concerned that it may not be 

appropriate to institute guidelines in the absence of State or Federal 

guidance. Several localities mentioned that it would be extremely 

valuable to have a single set of nationwide or statewide guidelines. As 

one official noted, “when you start to alter your protocols for patient 

care without the backing of statewide guidelines, you open yourself up 

to potential litigation.” 

Localities conduct exercises to test 

and improve their preparedness 

efforts. HPP and PHEP guidance 

require States to conduct exercises 

and encourage States to conduct these exercises pursuant to HSEEP 

requirements.35 Among other things, HSEEP requires participants to 

create an after-action report that documents the preparedness issues 

that arose during the exercise and an improvement plan that shows how 

participants will follow up on the lessons learned. 

All of the selected localities conducted medical 

surge exercises; however, none consistently 

documented the lessons learned

20 

35 Beginning in August 2008, all exercises associated with HPP and PHEP funding were 

required to meet HSEEP requirements for after-action reports and improvement plans. 

Note that this was not a requirement for any of the exercises reviewed for this study. 

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FINDINGS 

Localities conducted between one and seven medical surge exercises over 

a 2-year period 

Between mid-2006 and mid-2008, the 10 selected localities conducted a 

total of 41 exercises that focused on medical surge. Over half of these 

exercises were specific to a pandemic, whereas the remainder focused on 

other types of emergencies. As shown in Figure 1, the exercises most 

commonly focused on coordination among hospitals and other 

responders, followed by the management of medical equipment. Fewer 

exercises tested the use of alternate care sites; guidelines for altering 

triage, admission, and patient care; and volunteers. Most exercises 

focused on more than one medical surge component. 

Figure 1: 

Number of 

Exercises by 

Medical Surge 

Component

17

20 21

37

39

0

10

20

30

40

Coordination Medical

Equipment

Alternate

Care Sites

Triage,

Admission,

Patient Care

Volunteers

Number of Exercises

Source: OIG analysis of documentation from selected States and localities, 2009. 

Note: Most exercises focused on more than one medical surge component. 

Most of the medical surge exercises were discussion based, rather than 

operations based 

Discussion-based exercises can be used to identify and address gaps 

in preparedness plans before more resource-intensive operationsbased exercises are conducted. As shown in Table 1, over half of the 

41 medical surge exercises conducted by the 10 selected localities 

were discussion based and over a third were operations based. The 

remaining exercises were actual emergencies that localities evaluated 

for lessons learned. In total, 7 of the 10 localities conducted at least 

one discussion-based exercise and one operations-based exercise. 

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FINDINGS 

Table 1: Number of Exercises, by Type of Exercise 

Type of Exercise Number of 

Exercises

Percentage 

of Exercises 

Discussion-based 23 56% 

Operations-based 15 37% 

Based on Actual Emergencies 3 7% 

 Total 41 100% 

Source: OIG analysis of documentation from selected States and localities, 2009. 

Localities’ discussion-based exercises typically involved discussions by 

participants regarding potential responses to simulated scenarios in an 

informal setting. These types of exercises most commonly involved a 

facilitator who described a mock emergency to the participants. During 

each phase of the mock emergency—hour-by-hour or week-by-week—the 

participants discussed how they would respond. Typically, the 

facilitator prompted the participants with predetermined questions. 

For example, as part of one locality’s exercise, the facilitator described a 

scenario, stating that “It is now three hours into the incident. You are 

at capacity for beds. Your staffing is at 83 percent of your 

requirements . . . .” The facilitator then posed a variety of questions to 

participants, such as: “What are your top five priorities now?”; “What 

are your alternate care site plans?”; and “What do you need to do with 

regard to medical supplies?” 

In contrast, localities’ operations-based exercises typically occurred in 

participants’ actual work environments and participants physically 

responded to a mock emergency. For example, in one exercise, the 

following events were communicated to participants in hospitals via 

radio: “Local Emergency Operations Centers requesting update on 

hospital status by 9 a.m.” and “Some hospitals are reporting influx of 

people . . . .” Participants then had to respond and provide their status. 

Some of the operations-based exercises also involved the actual delivery 

of equipment and supplies or an influx of mock patients to hospitals. 

In addition, three localities experienced actual emergencies that they 

evaluated for lessons learned. For example, one locality evaluated its 

medical surge response to an ice storm in which staff at local hospitals, 

the public health department, the Red Cross, and emergency 

management coordinated to establish and run shelters for 400 residents 

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FINDINGS 

over 10 days. Another locality evaluated how it responded to a local 

shooting in which numerous people were admitted to the hospital. 

Localities did not consistently document the lessons learned from 

exercises 

As noted earlier, localities are encouraged to document lessons learned 

during exercises through the creation of after-action reports and 

improvement plans. None of the 10 localities had completed an 

after-action report and an improvement plan for all of their exercises. 

However, all of the localities had completed either an after-action report 

or an improvement plan for at least one of their exercises. 

For 9 of the 41 exercises, localities completed neither after-action 

reports nor improvement plans. For another 20 exercises, localities 

completed only after-action reports. For the remaining 12 exercises, 

they completed both after-action reports and improvement plans. See 

Figure 2. 

No After-Action Report and 

No Improvement Plan

(9 Exercises; 22%)

After-Action Report Only

(20 Exercises; 49%)

After-Action Report and 

Improvement Plan

(12 Exercises; 29%)

Figure 2: 

Number of 

Exercises With 

After-Action 

Reports and 

Improvement Plans

Source: OIG analysis of documentation from selected States and localities, 2009.

Localities reported several problems with preparing after-action reports 

and improvement plans. Specifically, they mentioned difficulties with 

conforming to HSEEP requirements that specify the format of and type 

of information that needs to be included in after-action reports and 

improvement plans. One locality reported that these requirements were 

not “hospital-friendly,” while another locality reported needing a 

full-time person to complete all of the required documents. 

 O E I - 0 2 - 0 8 - 0 0 2 1 0 S TATE AND L OCAL PANDEMIC I NFLUENZA P REPAREDNESS : MEDICAL S URGE 23 
FINDINGS 

Exercises showed that localities needed to make improvements within the 

five medical surge components 

The after-action reports from the exercises we reviewed showed that 

localities needed to make improvements within the five medical surge 

components. In particular, several reports highlighted the need for 

better coordination among stakeholders as well as the need for a better 

understanding of their roles and responsibilities during an emergency. 

Other reports focused on the need to improve coordination with 

emergency management agencies as well as enhance coordination with 

health care entities, such as long term care facilities and clinics. 

After-action reports also highlighted difficulties with medical 

equipment. Several reports indicated that localities had not assessed 

their equipment needs or could not deploy existing equipment. These 

reports also indicated that hospitals did not have plans for dealing with 

equipment shortages. One report pointed out that the locality had not 

established agreements among its hospitals to help facilitate the 

sharing of equipment. 

A few after-action reports also showed a need for localities to make 

improvements within the other medical surge components. These 

reports cited a need for localities to start or continue to plan for 

alternate care sites, specifically in terms of establishing who would 

manage and staff the sites. For example, one report noted that local 

hospitals and the public health department disagreed over who would 

open alternate care sites. Several reports also showed the need for 

localities to recruit additional medical volunteers, such as medical and 

nursing students. Another report noted that the locality should 

consider developing guidelines for altering patient care and determine 

the legality of adopting these guidelines. 

 O E I - 0 2 - 0 8 - 0 0 2 1 0 S TATE AND L OCAL PANDEMIC I NFLUENZA P REPAREDNESS : MEDICAL S URGE 24 
Δ RECOMMENDATIONS 

The recent public health emergency caused by an outbreak of human 

cases of H1N1 influenza has highlighted the need for States and 

localities to be prepared for a medical surge. Our review found that 

although the selected States and localities are making progress within 

the five components of medical surge that we reviewed, more needs to 

be done to improve States’ and localities’ ability to respond to a 

pandemic. 

Specifically, we found that in preparation for a pandemic, all of the 

10 selected localities had established partnerships to prepare for a 

medical surge; however, the degree to which this coordination occurred 

varied. We also found that fewer than half of the selected localities had 

started to recruit medical volunteers, and none of the five States had 

implemented an electronic system to manage these volunteers. 

Similarly, all selected localities had acquired limited medical equipment 

for a pandemic, but only three of the five States had electronic systems 

to track available beds and equipment. In addition, most of the selected 

localities were in the early stages of planning for alternate care sites, 

and most localities had not identified guidelines for altering triage, 

admission, and patient care during a pandemic. Finally, although all of 

the selected localities conducted medical surge exercises, none 

consistently documented the lessons learned. 

Based on these findings, we recommend that ASPR, in collaboration 

with CDC: 

Work with States and localities to improve their efforts within each 

of the five components of medical surge that we reviewed 

• ASPR should continue to emphasize the importance of coordination and 

involving a wide array of stakeholders in medical surge and pandemic 

planning. Specifically, additional guidance should focus on integrating 

local hospitals into emergency response planning as well as 

emphasizing the importance of including other health care providers—

such as nursing homes, home health agencies, clinics, and physicians—

in pandemic planning efforts. In addition, ASPR should collaborate 

with CDC to ensure that public health officials are actively involved in 

medical surge preparedness activities. 

• ASPR should continue to emphasize the importance of recruiting, 

registering, and training medical volunteers for use in a pandemic. In 

addition, ASPR should continue to monitor States’ progress in 

developing electronic systems (pursuant to the guidelines established 

 O E I - 0 2 - 0 8 - 0 0 2 1 0 S TATE AND L OCAL PANDEMIC I NFLUENZA P REPAREDNESS : MEDICAL S URGE 25 
RECOMMENDATIONS 

for ESAR-VHP) to register volunteers and verify credentials. ASPR 

should also encourage States and localities to make use of existing 

Federal volunteer programs, such as the Medical Reserve Corps. 

• ASPR should continue to emphasize the importance of managing 

medical equipment currently being stockpiled for a public health 

emergency, such as a pandemic. Specifically, ASPR should consider 

providing guidance on how best to store, maintain, and transport 

medical equipment. In addition, ASPR should consider providing 

guidance on the tracking of medical equipment in addition to the 

tracking of available hospital beds. 

• ASPR should continue to emphasize the importance of planning for 

alternate care sites for use during a pandemic. ASPR should include 

specific guidance about determining the scope of care to be provided at 

alternate care sites and how the sites can be managed, staffed, and 

supplied. 

• ASPR should emphasize the importance of identifying and adopting 

guidelines for altering triage, admission, and patient care during a 

pandemic. ASPR should consider developing guidelines for altering 

standards of care during a pandemic. These guidelines could serve as 

a model for States. In addition, ASPR should strengthen current 

guidance to encourage hospitals and other health care providers to 

make uniform decisions during a pandemic.

Ensure that States and localities consistently document the lessons 

learned from preparedness exercises that address medical surge 

Given the importance of exercises in strengthening preparedness, 

ASPR, in collaboration with CDC, should ensure that States and 

localities consistently document the lessons learned from all medical 

surge exercises that require HSEEP compliance. ASPR and CDC 

should conduct additional reviews to ensure that such exercises are 

meeting HSEEP requirements. 

Address the issue of legal protections for medical professionals and 

volunteers who respond to public health emergencies, such as an 

influenza pandemic 

ASPR should consider working with States to develop appropriate legal 

protections for medical professionals and volunteers who respond to public 

health emergencies, such as an influenza pandemic, and who may need to 

alter standards of care. ASPR should also consider the feasibility of 

Federal legislation in this area. Additionally, ASPR should encourage 

States and localities to inform health care providers about liability issues 

 O E I - 0 2 - 0 8 - 0 0 2 1 0 S TATE AND L OCAL PANDEMIC I NFLUENZA P REPAREDNESS : MEDICAL S URGE 26 
RECOMMENDATIONS 

using documents such as AHLA’s “Community Pan-Flu Preparedness: A 

Checklist of Key Legal Issues for Healthcare Providers.”

Facilitate the sharing of information and emerging practices 

among States and localities 

ASPR, in collaboration with CDC, should collect information on 

emerging practices from States and localities, as well as experts in the 

field, to further improve medical surge preparedness. These efforts 

should focus particularly on planning for alternate care sites and 

identifying and adopting guidelines for altered standards of care. ASPR 

should employ a variety of strategies to facilitate the sharing of 

information and emerging practices among States and localities. For 

example, ASPR could develop a secure Web site or listserv where States 

and localities could compare themselves to other States and localities 

with similar characteristics and share information. ASPR could also 

provide a mentoring program for State officials responsible for 

preparedness as well as develop additional opportunities for in-person 

meetings. 

Provide training and technical assistance to States and localities on 

key issues 

ASPR, in collaboration with CDC, should provide training and technical 

assistance to States and localities to bolster their medical surge 

preparedness efforts. ASPR should address specific State and local 

challenges, such as identifying alternate care sites, managing medical 

equipment, and identifying guidelines for alternate standards of care. 

ASPR should use its partnerships with existing groups, such as the 

National Association of County and City Health Officials, the 

Association of State and Territorial Health Officials, and the American 

Hospital Association, to help facilitate these activities. 

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

ASPR concurred with all five of our recommendations. The full text of 

ASPR’s comments is provided in Appendix B. CDC did not formally 

comment, but did provide technical comments. We made changes to the 

final report based on CDC’s technical comments, as appropriate. 

 O E I - 0 2 - 0 8 - 0 0 2 1 0 S TATE AND L OCAL PANDEMIC I NFLUENZA P REPAREDNESS : MEDICAL S URGE 27 
 

Δ 

State Locality 

Maine Portland 

Lewiston 

Missouri Saint Louis 

Rolla 

South Dakota Sioux Falls 

Mitchell 

Virginia Virginia Beach 

Blacksburg 

Washington Seattle 

Longview 

APPENDIX~A

Selected States and Localities 

 O E I - 0 2 - 0 8 - 0 0 2 1 0 S TATE AND L OCAL PANDEMIC I NFLUENZA P REPAREDNESS : MEDICAL S URGE 28 
.. A P PEN D x B

Agency Comments

¡l'if,IIVIc, (~~.,'~~

DEPARTMNT OF HEALTH & HUAN SERVICES Offce of the Seretary

Assistant Secretary for

Prepa'ØIness & Response

Washlnglon. 0.0.20201

DA'ff: September 1, 2009

TO: Stuar Wright

Deputy Inpector General for Evaluation and Inspections

FROM: Gerald W. Parker, DVM, PhD, MS

Principal Deputy Assistat Secreta for Preparedness and Response

SUBJECT: OIG Draft Report: "State and LocalPandemic InfuenZ Preparedness: Medícal

Surge," OEI-02-08-0021 0

The Offce of the Assistat Secreta for Preparedness and Response (ASPR) apprecíates the

opportty to review and respond to the Offce ofInspector Geneta's (OIG) dr report

entitled, "State and Local Pandemic Infuenza Praredness: Medical Surge," OEI-02-08-00210.

om Recomiuendations

. Work with States and localiies to improve tbeir efforts within each oftbe five

components of medical surge tbat we reviewed.

o ASPR should continue to emphasize the importance of coordination and involving a wide

aray of steholders in medical surge and pandemic plan.

o ASPR should continue to emphasize the importce of recruiting, registering, and

traing medical volunteers for use in a pandemic.

o A8PR should contiue to emphaize the importce of manging medical equipment

curently being stockpiled for a public health emergency such as a pandemic.

o ASPR should continue to emphaize the importce of planng for alternate care sites

for use durg a pandemic.

o ASPR should emphasize the importce of identifYing and adopting gudelines for

alterig triage, admission, and patient care during a pandemc.

. Ensure that states and localitiescbnsistentlydocuiuent the lessons learned from

preparedness exercises that address médicalsurge.

. Address the issue onegal protections foriuedical profllsionals andVblunteers wbo

respond to public health eiuergencies, such as an influenza pandemic.

. ASPR sbould consider working witbStates to faciltate the sharing of information and

emerging practices among States and localities.

. Provide training and technical assistance to States and localities on key issués.

ASPR Resllonse

We concur with these recomiendationsand look forward to working with the OIG on this issue.

OEI.02.08.00210 STATE AND LOCAL PANDEMIC INFLUENZA PREPAREDNESS: MEDICAL SURGE 29
Δ ACKNOWLEDGMENTS

This report was prepared under the direction of Jodi Nudelman, 

Regional Inspector General for Evaluation and Inspections in the 

New York regional office, and Meridith Seife, Deputy Regional Inspector 

General. 

Judy Kellis served as the team leader for this study. Other principal 

Office of Evaluation and Inspections staff from the New York regional 

office who contributed to the report include Judy Bartlett and 

Christine Moundas; central office staff who contributed include 

Talisha Searcy and Robert Gibbons. 

 O E I - 0 2 - 0 8 - 0 0 2 1 0 S TATE AND L OCAL PANDEMIC I NFLUENZA P REPAREDNESS : MEDICAL S URGE 30