Report to Congressional Committees 

United States General Accounting Office 

GAO 

August 2003 HOSPITAL 

PREPAREDNESS 

Most Urban Hospitals 

Have Emergency 

Plans but Lack Certain 

Capacities for 

Bioterrorism 

Response 

GAO-03-924 
While most urban hospitals across the country reported participating in 

basic planning and coordination activities for bioterrorism response, they 

did not have the medical equipment to handle the number of patients that 

would be likely to result from a bioterrorist incident. Four out of five 

hospitals reported having a written emergency response plan addressing 

bioterrorism, but many plans omitted some key contacts, such as other 

laboratories. Almost all hospitals reported participating in a local, state, or 

regional interagency disaster preparedness committee. In addition, most 

hospitals reported having provided at least some training to their personnel 

on identification and diagnosis of disease caused by biological agents 

considered likely to be used in a bioterrorist attack, such as anthrax or 

botulism. In contrast, fewer than half of hospitals have conducted drills or 

exercises simulating response to a bioterrorist incident. Hospitals also 

reported that they lacked the medical equipment necessary for a large influx 

of patients. For example, if a large number of patients with severe 

respiratory problems associated with anthrax or botulism were to arrive at a 

hospital, a comparable number of ventilators would be required to treat 

them. Yet half of hospitals reported having fewer than six ventilators per 100 

staffed beds. In general, larger hospitals reported more planning and training 

activities than smaller hospitals. 

Representatives from the American Hospital Association provided oral 

comments on a draft of this report, which GAO incorporated as appropriate. 

They generally agreed with the findings. 

Urban Hospitals with Ventilator Capabilities, per 100 Staffed Beds 

Ventilators Percentage of hospitals 

Less than 2 ventilators 9.0 

2 to less than 5 ventilators 33.9 

5 to less than 10 ventilators 39.7 

10 or more ventilators 17.4 

Total 100.0 

Source: GAO. 

Note: Data are from GAO’s 2002 survey of hospitals and their emergency departments. Responses 

were weighted to provide estimates for the universe of hospitals. 

In the event of a large-scale 

infectious disease outbreak, as 

could be seen with a bioterrorist 

attack, hospitals and their 

emergency departments would be 

on the front line. Federal, state, and 

local officials are concerned, 

however, that hospitals may not 

have the capacity to accept and 

treat a sudden, large increase in the 

number of patients, as might be 

seen in a bioterrorist attack. In the 

Public Health Improvement Act 

that was passed in 2000, Congress 

directed GAO to examine 

preparedness for a bioterrorist 

attack. In this report GAO provides 

information on the extent of 

bioterrorism preparedness among 

hospitals in urban areas in the 

United States. 

To conduct this work, GAO 

surveyed over 2,000 urban 

hospitals and about 73 percent 

provided responses addressing 

emergency preparedness. The 

survey collected information on 

hospital preparedness for 

bioterrorism, such as data on 

planning activities, staff training, 

and capacity for response. 

www.gao.gov/cgi-bin/getrpt?GAO-03-924.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Marcia Crosse 

on (202) 512-7119. 

Highlights of GAO-03-924, a report to the 

Senate Committee on Health, Education, 

Labor, and Pensions; the Senate and 

House Committees on Appropriations; and 

the House Committee on Energy and 

Commerce 

August 2003 

HOSPITAL PREPAREDNESS 

Most Urban Hospitals Have Emergency 

Plans but Lack Certain Capacities for 

Bioterrorism Response 
Page i GAO-03-924 Hospital Bioterrorism Preparedness 

Letter 1

Results in Brief 2

Background 3

Hospitals Reported Planning for Bioterrorism Response but Do Not 

Have Certain Medical Capacities to Handle a Large Increase in 

Patient Load 8

Concluding Observations 16

Comments from the American Hospital Association 17

Appendix I Selected Results of GAO Survey of Hospitals 

Regarding Hospital Preparedness for Bioterrorism 19 

Appendix II Scope and Methodology 35 

Appendix III GAO Contact and Staff Acknowledgments 37 

GAO Contact 37

Acknowledgments 37

Related GAO Products 38 

Tables 

Table 1: Percentage of Urban Hospitals Participating in an 

Interagency Disaster Preparedness Committee That Also 

Includes Members from Specified Organization 12

Table 2: Urban Hospitals with Medical Equipment Capabilities, per 

100 Staffed Beds 15

Table 3: Characteristics of Hospitals in Survey 20

Table 4: Number of Hospitals That Were Sent Survey, Number That 

Responded to Survey, and Percentage of Hospitals That 

Responded to Survey, by State and District of Columbia 21

Table 5: Percentage of Urban Hospitals with a Written Emergency 

Response Plan Addressing Bioterrorism, by State 23

Table 6: Percentage of Urban Hospitals That Reported Specifying 

in Emergency Response Plan to Contact the Specified 

Entities during an Emergency, by State 25

Contents 
Page ii GAO-03-924 Hospital Bioterrorism Preparedness 

Table 7: Percentage of Urban Hospitals Whose Mass Casualty Plans 

Address Bioterrorism and Describe How to Manage the 

Specified Function, by State 27

Table 8: Percentage of Urban Hospitals That Had Agreements with 

Other Hospitals or City, County, State, and Regional 

Organizations to Provide or Share Resources in the Event 

of Bioterrorism, by State 29

Table 9: Percentage of Urban Hospitals That Have Provided 

Training to Staff (Services, Courses, or Self-Learning 

Materials) to Identify and Diagnose Symptoms for the 

Following Biological Agents, by State 31

Table 10: Percentage of Urban Hospitals That Participated in Mass 

Casualty Drills Related to Biological Incidents by State 33

Figures 

Figure 1: Percentage of Urban Hospitals with a Written Emergency 

Response Plan Addressing Bioterrorism 9

Figure 2: Percentage of Urban Hospitals That Reported Specifying 

in Emergency Response Plan to Contact the Specified 

Entity during an Emergency 10

Figure 3: Percentage of Urban Hospitals Whose Emergency 

Response Plans Addressed Bioterrorism and Included a 

Description of How to Manage the Specified Function 11

Figure 4: Percentage of Urban Hospitals That Have Agreements 

with Other Hospitals or City, County, State, or Regional 

Organizations to Provide or Share Resources in the Event 

of Bioterrorism 13

Figure 5: Percentage of Urban Hospitals That Have Provided Staff 

with Training (Services, Courses, or Self-Learning 

Materials) about Identifying and Diagnosing Symptoms 

for Each of the Following Biological Agents 14
Page iii GAO-03-924 Hospital Bioterrorism Preparedness 

Abbreviations 

EMS emergency medical services 

HAZMAT hazardous materials 

HHS Department of Health and Human Services 

HRSA Health Resources and Services Administration 

MSA metropolitan statistical area 

PPE personal protective equipment 

SARS Severe Acute Respiratory Syndrome 

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. It may be reproduced and distributed in its entirety without further 

permission from GAO. However, because this work may contain copyrighted images or 

other material, permission from the copyright holder may be necessary if you wish to 

reproduce this material separately. 
Page 1 GAO-03-924 Hospital Bioterrorism Preparedness 

August 6, 2003 

Congressional Committees 

In the event of a large-scale infectious disease outbreak, as could be seen 

with a bioterrorist attack, hospitals and their emergency departments 

would be on the front line. The release of a biological agent by a terrorist 

might not be recognized for several days, during which time a 

communicable disease could be spread to many people who were not 

initially exposed. Because hospitals are open 24 hours a day, 7 days a 

week, victims would be likely to seek treatment of their symptoms there, 

putting hospital personnel in the role of first responders. Federal, state, 

and local officials are concerned, however, that hospitals may not have the 

capacity to accept and treat a sudden, large increase in the number of 

patients, as might be seen in a bioterrorist attack.1

 For example, these 

officials are concerned that this surge in patients would be likely to 

overwhelm emergency departments in urban areas, many of which are 

already operating at or above capacity.2

The Public Health Improvement Act directed that we examine state and 

local levels of preparedness for a bioterrorist attack.3

 We have previously 

reported on activities by federal agencies and state and local public health 

agencies and health care organizations, including hospitals, to prepare for 

and respond to bioterrorism.4

 In this report we are providing you with 

additional information on the extent of bioterrorism preparedness among 

urban hospitals in the United States, specifically with respect to planning 

activities, staff training, and capacity for response. 

 1

U.S. General Accounting Office, Bioterrorism: Preparedness Varied Across State and 

Local Jurisdictions, GAO-03-373 (Washington, D.C.: Apr. 7, 2003). 

2

For information on emergency department capacity, see U.S. General Accounting Office, 

Hospital Emergency Departments: Crowded Conditions Vary among Hospitals and 

Communities, GAO-03-460 (Washington, D.C.: Mar. 14, 2003) and The Lewin Group, 

Emergency Department Overload: A Growing Crisis; The Results of the AHA Survey of 

Emergency Department (ED) and Hospital Capacity, April 2002. 

3

Pub. L. No. 106-505, § 102, 114 Stat. 2314, 2323 (2000). 

4

U.S. General Accounting Office, Bioterrorism: Federal Research and Preparedness 

Activities, GAO-01-915 (Washington, D.C.: Sept. 28, 2001) and GAO-03-373. 

United States General Accounting Office

Washington, DC 20548 
Page 2 GAO-03-924 Hospital Bioterrorism Preparedness 

To obtain information on the extent of hospital bioterrorism preparedness, 

we conducted a survey between May and September 2002 of 2,041 urban 

hospitals across the country that have emergency departments. (See app. I 

for a description of the hospitals we surveyed.) The survey asked 

questions relating to emergency room functioning and hospital 

bioterrorism preparedness. We reported our survey findings on emergency 

room functioning in March 2003.5

 We obtained responses to the survey 

addressing bioterrorism preparedness from 1,482 hospitals, for a response 

rate of 73 percent and we are providing our survey findings in the current 

report. The survey covered key components of hospital preparedness for 

bioterrorism, including planning activities related to communication and 

coordination with community and state organizations (e.g., participation in 

an interagency disaster preparedness committee); staff training; and the 

response capacity of the facility (e.g., number of isolation beds) and of the 

equipment (e.g., number of ventilators6

). We weighted responses to adjust 

for a lower response rate from investor-owned (for-profit) hospitals to 

provide estimates representative of the entire universe of urban hospitals 

we surveyed. Our report reflects hospital preparedness at the time of our 

survey in 2002. Improvements in hospital preparedness may have occurred 

since these data were collected. (For more detail on our scope and 

methodology, see app. II.) We did our work from May 2002 through July 

2003 in accordance with generally accepted government auditing 

standards. 

While most hospitals in urban areas across the country reported 

participating in basic planning and coordination activities for bioterrorism 

response, they did not have the medical equipment to handle the large 

increase in the number of patients that would be likely to result from a 

bioterrorist incident. Four out of five hospitals reported having a written 

emergency response plan addressing bioterrorism, but many plans omitted 

some key contacts, such as laboratories outside the hospital. Almost all 

hospitals reported participating in a local, state, or regional interagency 

disaster preparedness committee. In addition, most hospitals reported 

having provided at least some training to their personnel on identification 

and diagnosis of disease caused by biological agents considered likely to 

be used in a bioterrorist attack, such as anthrax or botulism. In contrast, 

 5

GAO-03-460. 

6

A ventilator is a mechanical device designed to perform part or all of the work of the 

lungs. 

Results in Brief 
Page 3 GAO-03-924 Hospital Bioterrorism Preparedness 

fewer than half of hospitals have conducted drills or exercises simulating 

response to a bioterrorist incident. Hospitals also reported that they 

lacked the medical equipment necessary for a large influx of patients. For 

example, if a large number of patients were to arrive at a hospital with 

severe respiratory problems associated with anthrax or botulism, a 

comparable number of ventilators would be required to treat them. Yet 

half of hospitals reported having fewer than six ventilators per 100 staffed 

beds. In general, larger hospitals reported more planning and training 

activities than smaller hospitals. 

Representatives of the American Hospital Association provided oral 

comments on a draft of this report, which we incorporated as appropriate. 

They generally agreed with our findings. 

The resources that hospitals and their emergency departments would 

require for responding to a large-scale bioterrorist attack are far greater 

than those needed for everyday performance. The specific equipment, 

supplies, and facilities needed could vary depending upon what type of 

attack occurred, but many scenarios anticipate that the demand for health 

care could quickly outstrip the ability of hospitals to respond. For 

example, the TOPOFF 2000 exercise7

 testing terrorism preparedness 

included a bioterrorism scenario of an attack using pneumonic plague8

released at a public event in a single location in one city. In this exercise, 

officials found that by the third day following the covert release, 500 

persons with symptoms had been reported and antibiotic and ventilator 

shortages were beginning to occur. By the end of this day, nearly 800 cases 

were identified and over 100 persons had died. In each of the succeeding 2 

days, the situation worsened and medical care in the city was described as 

beginning to shut down, with insufficient hospital staff, beds, ventilators, 

and drugs. At the conclusion of the exercise, 1 week after the attack, an 

estimated 3,700 cases of plague had been reported, with 950 to 2,000 

deaths, including cases in other cities and abroad. In the early stages of the 

epidemic, hospitals were seeing 2 to 3 times their normal volume of 

 7

TOPOFF, so named for the involvement of top officials of the U.S. government, was a set 

of exercises assessing readiness to respond to terrorist attacks. 

8

Pneumonic plague is a contagious disease that can be spread from person to person by 

respiratory droplet. Its symptoms include cough and fever, progressing to respiratory 

failure and shock. Pneumonic plague can be treated with some success by antibiotics if 

treatment is given within 24 hours of the first symptoms. For untreated pneumonic plague, 

mortality approaches 100 percent. 

Background 
Page 4 GAO-03-924 Hospital Bioterrorism Preparedness 

patients and later in the exercise up to 10 times normal volumes were 

arriving at hospitals. Hospitals were not able to effectively isolate patients 

to prevent the spread of the disease to hospital staff. 

In order to be adequately prepared for bioterrorism, hospitals would need 

to have several basic capabilities, whether they possess them directly or 

have access to them through regional agreements. Plans that describe how 

hospitals would work with state and local officials to manage and 

coordinate an emergency response would need to be in place and to have 

been tested in an exercise, both at the state and local levels and at the 

regional level. Regional plans can help address capacity deficiencies by 

providing for the sharing, among hospitals and other community and state 

agencies and organizations, of resources that, while adequate for everyday 

needs, may be in short supply on a local level in an emergency. In addition, 

hospitals would need to be able to communicate easily with all 

organizations involved in the response as events unfold and critical 

information is acquired. Staff would need to be able to recognize and 

report to their state or local health department any illness patterns or 

diagnostic clues that might indicate an outbreak of a disease caused by a 

biological agent likely to be used by a terrorist.9

 Finally, hospitals would 

need to have the capacity and staff necessary to treat large numbers of 

severely ill patients and limit the spread of infectious disease. They would 

need adequate stores of equipment and supplies, including medications, 

personal protective equipment, quarantine and isolation facilities,10 and air 

handling and filtration equipment. 

Many of the capabilities required for responding to a large-scale 

bioterrorist attack are also required for response to naturally occurring 

disease outbreaks. Such a “dual-use” response infrastructure improves the 

capacity of local public health agencies to respond to all hazards. For 

example, a large-scale outbreak of Severe Acute Respiratory Syndrome 

 9

The Centers for Disease Control and Prevention (CDC) considers anthrax, botulism, 

plague, smallpox, tularemia, and hemorrhagic fever viruses as the six biological agents that 

pose the greatest potential threat for adverse public health impact and have a moderate to 

high potential for large-scale dissemination. 

10Quarantine facilities limit the freedom of movement of an individual and restrict visitors 

to prevent the spread of a disease to other members of the population, and could be 

created by separately housing affected individuals in an existing portion of a hospital. 

Isolation facilities provide a treatment setting that includes special or separate equipment 

such as air filters to limit the possibility of disease spread. 
Page 5 GAO-03-924 Hospital Bioterrorism Preparedness 

(SARS) would require many of the same capabilities that would be needed 

to respond to an intentionally caused epidemic.11

Prior to our survey, efforts had been made by organizations to assist 

hospitals in preparing for bioterrorism. For example, the American 

Hospital Association distributed a checklist to help hospitals describe and 

assess their state of preparedness for chemical and biological incidents.12

This checklist covered, for example, emergency response plans for 

hospital operations during a biological or chemical disaster; emergency 

preparedness training of the workers; and the hospital’s ability to increase 

its capacity—for example, in terms of such items as ventilators and 

decontamination equipment—in the event of a large number of patients 

seeking care. Another organization, the Association for Professionals in 

Infection Control and Epidemiology, developed a mass casualty disaster 

plan checklist for health care facilities, including hospitals.13 This checklist 

included disease surveillance activities,14 communication systems, plans 

for receiving and treating casualties, and plans for the organized discharge 

of nonemergency patients on short notice. 

Nevertheless, in our April 2003 report,15 we noted the general lack of 

guidance on what capacities hospitals should have to be prepared for 

bioterrorism. We also noted that efforts to improve hospitals’ bioterrorism 

response capacities must be mindful that hospitals face multiple 

 11U.S. General Accounting Office, Infectious Disease Outbreaks: Bioterrorism 

Preparedness Efforts Have Improved Public Health Response Capacity, but Gaps 

Remain, GAO-03-654T (Washington, D.C.: Apr. 9, 2003), U.S. General Accounting Office, 

SARS Outbreak: Improvements to Public Health Capacity Are Needed for Responding to 

Bioterrorism and Emerging Infectious Diseases, GAO-03-769T (Washington, D.C.: 

May 7, 2003), and Severe Acute Respiratory Syndrome: Established Infectious Disease 

Control Measures Helped Contain Spread, But a Large-Scale Resurgence May Pose 

Challenges, GAO-03-1058T. Washington, D.C.: July 30, 2003. 

12A. David Mangelsdorff, Chemical and Bioterrorism Preparedness Checklist (Chicago: 

American Hospital Association, Oct. 3, 2001), 

http://hospitalconnect.com/aha/key_issues/disaster_readiness/resources/HospitalReady.ht

ml (downloaded Apr. 22, 2003). 

13Center for the Study of Bioterrorism & Emerging Infections, Mass Casualty Disaster 

Plan Checklist: A Template for Healthcare Facilities (Washington, D.C.: Association for 

Professionals in Infection Control and Epidemiology, Inc., Oct. 1, 2001), 

http://www.apic.org/bioterror/checklist.doc (downloaded Apr. 23, 2003). 

14Disease surveillance is the monitoring of health-related data to identify, prevent, and 

control disease. 

15GAO-03-373. 
Page 6 GAO-03-924 Hospital Bioterrorism Preparedness 

challenges, including having to prepare for other types of disasters and 

continuing to meet the everyday needs of cities for emergency care. In that 

report, among other things, we recommended that the Department of 

Health and Human Services (HHS) develop specific benchmarks that 

define adequate preparedness for a bioterrorist attack and can be used to 

guide preparedness efforts. 

Since our survey, there have been continuing efforts to assist hospitals in 

bioterrorism preparedness. For example, the Joint Commission on 

Accreditation of Healthcare Organizations released a report in 2003 on 

strategies for creating and sustaining communitywide preparedness 

systems for health care organizations, including hospitals.16 The report 

outlined critical issues to be addressed in developing communitywide 

preparedness and discussed federal and state responsibilities for 

eliminating barriers to preparedness and for facilitating and sustaining 

hospital and community-based emergency preparedness. It called for 

hospitals to address the full range of potential disasters, including 

terrorism, in their planning and to be aware of the specific hazards 

applicable to their communities. 

The federal government has also provided assistance for improving the 

bioterrorism preparedness of hospitals. In January 2002 HHS announced 

the availability of funding for that purpose.17 The Bioterrorism Hospital 

Preparedness Program, administered by HHS’s Health Resources and 

Services Administration (HRSA), provided funding in fiscal year 2002 of 

approximately $125 million through cooperative agreements to states and 

eligible municipalities to enhance the capacity of hospitals and associated 

health care entities to respond to bioterrorism.18

 16Joint Commission on Accreditation of Healthcare Organizations, Health Care at the 

Crossroads: Strategies for Creating and Sustaining Community-wide Emergency 

Preparedness Systems (Oakbrook Terrace, Il.: 2003). 

17The funds were primarily appropriated by the Department of Defense and Emergency 

Supplemental Appropriations for Recovery from and Response to Terrorist Attacks on the 

United States Act, Pub. L. No. 107-117, 115 Stat. 2230, 2314 (2002), and Departments of 

Labor, Health and Human Services, and Education, and Related Agencies Appropriations 

Act of Fiscal Year 2002, Pub. L. No. 107-116, 115 Stat. 2186, 2198. 

18The four eligible municipalities were Chicago, the District of Columbia, Los Angeles 

County, and New York City. Funding was also provided to five American territories: 

American Samoa, Guam, the Northern Marianas Islands, Puerto Rico, and the U.S. Virgin 

Islands. 
Page 7 GAO-03-924 Hospital Bioterrorism Preparedness 

These noncompetitive cooperative agreements covered two phases. In the 

first phase, states and municipalities applying for this funding were 

required to develop a needs assessment for a comprehensive bioterrorism 

preparedness program for hospitals and other health care entities, such as 

community health centers, and an implementation plan, as well as to begin 

initial implementation of the plan. Applications for the first phase were 

due to HHS by February 25, 2002, and funding for this phase, 

approximately $25 million, was awarded shortly after receipt of 

applications. For the second phase, jurisdictions were required to submit 

more detailed implementation plans, in which they addressed three 

“critical benchmarks,” including a regional hospital plan for dealing with a 

potential epidemic involving at least 500 patients. In addition, applicants 

were to address four top-priority planning areas: medications and 

vaccines; personal protection, quarantine, and decontamination; 

communications; and biological disaster drills. Applications for the second 

phase were due April 15, 2002, and the additional funding, approximately 

$100 million, was awarded after HHS’s review and approval of the plans. In 

March 2003, HHS announced that HRSA’s National Bioterrorism Hospital 

Preparedness Program would provide funding in fiscal year 2003 of 

approximately $498 million through cooperative agreements to states and 

eligible municipalities.19 In response to our recommendations concerning 

additional guidance, HHS noted that it is developing some additional 

guidelines and templates to assist in preparedness efforts.20

In addition, the federal government has established a stockpile of 

pharmaceuticals, antidotes, and medical supplies that can be delivered to 

the site of a bioterrorist (or other) attack. This Strategic National Stockpile 

has recently been expanded and HHS disclosed that it is planning to 

purchase 2,700 ventilators by September 2003 to supplement those now 

available in the stockpile. These supplies could be deployed to the site of 

an attack within 12 to 36 hours following a declaration of an emergency. 

 19The four eligible municipalities are Chicago, the District of Columbia, Los Angeles 

County, and New York City. Funding will also be provided to five American territories: 

American Samoa, Guam, the Northern Marianas Islands, Puerto Rico, and the U.S. Virgin 

Islands, and to three freely associated states of the Pacific: Marshall Islands, Micronesia, 

and Palau. 

20GAO-03-373. 
Page 8 GAO-03-924 Hospital Bioterrorism Preparedness 

Most hospitals in urban areas across the country reported participating in 

basic planning and coordination activities for bioterrorism response. 

Although most hospitals reported providing at least some training to their 

personnel on identification and diagnosis of disease caused by biological 

agents considered likely to be used in a bioterrorist attack, only about half 

report they have conducted drills or exercises simulating response to a 

bioterrorist incident. Further, few reported having acquired the medical 

equipment to handle the large increase in the number of patients that 

would be likely to result from a bioterrorist incident. 

Our survey showed that hospitals have engaged in a variety of planning 

and coordination activities, with most having prepared an emergency 

response plan addressing bioterrorism; participated in a local, state, or 

regional interagency disaster preparedness committee; and made 

agreements with at least one other organization to share personnel or 

equipment in the event of a bioterrorist or other mass casualty incident. 

Four out of five hospitals reported having a written emergency response 

plan that specifically addresses bioterrorism (see fig. 1). Hospitals that had 

a plan were on average around 15 percent larger than those that did not in 

terms of number of staffed beds.21 Of those hospitals that reported not 

having such a plan, almost all were currently developing one. 

 21Staffed beds are the total facility beds set up and staffed as reported by hospitals in the 

American Hospital Association Annual Survey of Hospitals Database 2000. 

Hospitals Reported 

Planning for 

Bioterrorism 

Response but Do Not 

Have Certain Medical 

Capacities to Handle a 

Large Increase in 

Patient Load 

Most Hospitals Have 

Emergency Response 

Plans Addressing 

Bioterrorism and Are 

Participating in Local, 

State, or Regional Planning 

and Coordination 

Activities 
Page 9 GAO-03-924 Hospital Bioterrorism Preparedness 

Figure 1: Percentage of Urban Hospitals with a Written Emergency Response Plan 

Addressing Bioterrorism 

Note: Data are from our 2002 survey of hospitals and their emergency departments. Responses were 

weighted to provide estimates for the universe of hospitals. 

We asked hospitals whether certain elements were specified in their 

emergency response plan: contacting other response agencies and 

organizations in the event of a bioterrorist incident and managing various 

critical functions such as decontamination of victims. As shown in figure 

2, of the hospitals that reported having an emergency response plan for 

bioterrorism, approximately 90 percent reported specifying in their plan to 

contact state and local government agencies, public health agencies, other 

hospitals, hazardous materials (HAZMAT) teams, emergency medical 

services (EMS), fire departments, or law enforcement. These entities 

would be critical to mounting a larger communitywide response, 

communicating with the public, investigating and controlling sources of 

the outbreak, transporting patients, maintaining order, and investigating 

those responsible for the bioterrorism. Hospitals that planned to contact 

HAZMAT teams or public health agencies were on average around 15 and 

20 percent larger, respectively, than those that did not. There were no 

significant differences in average sizes of hospitals with respect to 

contacting any of the other entities. Approximately 75 percent of hospitals 

reported planning to contact public or private utilities, whose assistance 

could be needed to increase or maintain power supplies to critical 

equipment or to control water- or sewer-borne pathogens. Although 

establishing contact with other laboratories that could potentially provide 

81%

18%

1%

Have a plan

Developing a plan

Not developing a plan

Source: GAO.
Page 10 GAO-03-924 Hospital Bioterrorism Preparedness 

additional capacity for overstretched hospital laboratories would be 

critical, the percentage of hospitals planning to make that link was lowest, 

at approximately 60 percent. Approximately 40 percent of hospitals 

reported specifying contacting all nine types of entities listed in figure 2. 

Figure 2: Percentage of Urban Hospitals That Reported Specifying in Emergency 

Response Plan to Contact the Specified Entity during an Emergency 

Note: Data are from our 2002 survey of hospitals and their emergency departments. Responses were 

weighted to provide estimates for the universe of hospitals. Data are presented for hospitals that 

reported having an emergency response plan that addresses bioterrorism. 

As shown in figure 3, most of the hospitals that reported having an 

emergency response plan for bioterrorism indicated that they specified in 

that plan how certain critical functions were to be managed. The functions 

specified by more than 87 percent of hospitals included providing for 

hospital security to control entry to and exit from all parts of the hospital; 

obtaining additional staff, supplies, and pharmaceuticals to increase the 

hospital’s capacity to handle a surge of patients; or planning for mass 

evacuation of nonemergency patients on short notice. In general, larger 

hospitals had emergency response plans that covered more of these 

functions than the plans of smaller hospitals. Hospitals that reported 

addressing how to obtain additional pharmaceuticals for surge capacity, 

“worried well”22 management, and mass fatalities were on average around 

 22The “worried well” are people who think they may be infected but in fact are not. 

57.1

75.8

89.3

90.7

90.8

93.4

94.2

94.6

94.7

Other laboratories

Public or private utilities

Other hospitals

Other state and local

government agencies

HAZMAT

EMS

Fire

Law enforcement

Public health agencies

Source: GAO.

0 20 40 60 80 100

Percentage of hospitals
Page 11 GAO-03-924 Hospital Bioterrorism Preparedness 

15 percent larger than those that did not. There were no significant 

differences in average sizes of hospitals with respect to any of the other 

functions. Approximately 77 percent of the hospitals reported addressing 

the question of how to manage a large influx of the worried well and 

distinguish them from victims who may be in the early stages of illness. 

Approximately 50 percent of hospitals addressed the management of all of 

the critical functions listed in figure 3. 

Figure 3: Percentage of Urban Hospitals Whose Emergency Response Plans 

Addressed Bioterrorism and Included a Description of How to Manage the Specified 

Function 

Note: Data are from our 2002 survey of hospitals and their emergency departments. Responses were 

weighted to provide estimates for the universe of hospitals. Data are presented for hospitals that 

reported having an emergency response plan that addressed bioterrorism. 

Whether they had an emergency response plan addressing bioterrorism or 

not, more than 95 percent of hospitals reported participating in a local, 

state, or regional interagency disaster preparedness committee, task force, 

or working group. Most commonly, these committees also included 

representatives from city and county emergency medical services 

organizations, fire departments, city and county offices of emergency 

management, other local hospitals or medical institutions, city and county 

public health or health departments and agencies, and law enforcement 

organizations (see table 1). As we have previously reported,23 it was not 

 23GAO-03-373. 

Source: GAO.

94.8

96.1

76.8

76.7

90.5

87.3

95.9

92.8

98.2

0 20 40 60 80 100

Decontamination of victims

Mass patient management

Worried well management

Mass fatality management

Mass evacuation

Obtaining additional pharmaceuticals

for surge capacity

Obtaining additional staff

for surge capacity

Obtaining additional other supplies

for surge capacity

Hospital security

Percentage of hospitals
Page 12 GAO-03-924 Hospital Bioterrorism Preparedness 

until after September 11, 2001, that government and hospital officials came 

to view hospitals as an integral component in local planning for 

responding to a terrorist event. 

Table 1: Percentage of Urban Hospitals Participating in an Interagency Disaster 

Preparedness Committee That Also Includes Members from Specified Organization 

Percentage 

City and county emergency medical services organizations 94.0 

Fire departments 91.2 

City and county offices of emergency management 88.3 

Other local hospitals or other medical institutions 86.8 

City and county public health or health departments and agencies 86.6 

Law enforcement organizations 84.0 

State health or public health departments and agencies 47.0 

Professional organizations (e.g., emergency medicine organization, local 

medical society, hospital association) 46.6 

State office of emergency management 46.6 

Surrounding area mutual aid response organizations 43.9 

Public or private utilities (such as water and power) 37.6 

State law enforcement organizations 36.7 

Board of supervisors or other elected officials 34.4 

Freestanding HAZMAT organizations 33.2 

Public or private transportation organizations 31.1 

State office of emergency medical services 29.8 

Federal Bureau of Investigation 24.8 

Federal Emergency Management Agency 21.2 

National Guard 18.3 

Centers for Disease Control and Prevention 11.3 

State office of fire control 10.7 

Department of Justice 8.4 

Source: GAO. 

Note: Data are from our 2002 survey of hospitals and their emergency departments. Responses were 

weighted to provide estimates for the universe of hospitals. Data are presented for hospitals that 

reported participating on an interagency disaster preparedness committee, task force, or working 

group. 
Page 13 GAO-03-924 Hospital Bioterrorism Preparedness 

Another planning and coordination activity that hospitals reported on in 

our survey was their participation in agreements to share or provide 

resources in the event of a bioterrorist or other mass casualty incident. We 

asked about agreements at the hospital, city, county, state, and regional 

levels. The survey results indicated that hospitals mostly coordinated with 

other hospitals, about half coordinated with the local government, and 

about one-third coordinated at the state or regional level to provide or 

share resources. About 70 percent of hospitals reported that they had 

agreements, such as memoranda of understanding or mutual aid 

agreements, with other hospitals to provide or share personnel, 

equipment, or other resources (see fig. 4). Fewer (between 37 and 54 

percent) hospitals had agreements with regional, state, county, or city 

organizations (fig. 4). In general, hospitals that had agreements with other 

organizations were larger than those that did not. Hospitals that had 

agreements with other hospitals or with city organizations were on 

average around 10 percent larger than hospitals that did not. Fewer than 

20 percent of hospitals had agreements with entities at all five levels. 

Figure 4: Percentage of Urban Hospitals That Have Agreements with Other 

Hospitals or City, County, State, or Regional Organizations to Provide or Share 

Resources in the Event of Bioterrorism 

Note: Data are from our 2002 survey of hospitals and their emergency departments. Responses were 

weighted to provide estimates for the universe of hospitals. 

Approximately 7 out of 10 hospitals reported that their staff had received 

training (services, courses, or self-learning materials) for identifying and 

diagnosing illness caused by all six biological agents that CDC has stated 

would be most likely to be used in a bioterrorist incident (see fig. 5). 

Hospitals that reported training activities for all of the biological agents 

were on average around 15 percent larger than hospitals that did not. A 

greater percentage of hospitals reported that staff had received training for 

anthrax or smallpox (around 90 percent or more) than for plague or 

Staff Training on Biological 

Agents Was Reported to Be 

Widespread, While 

Hospital Participation in 

Drills Was Less Common 
Page 14 GAO-03-924 Hospital Bioterrorism Preparedness 

botulism (approximately 80 percent) or tularemia or hemorrhagic fever 

viruses (approximately 70 percent). However, the extensiveness of the 

reported training cannot be determined from our survey. 

Figure 5: Percentage of Urban Hospitals That Have Provided Staff with Training 

(Services, Courses, or Self-Learning Materials) about Identifying and Diagnosing 

Symptoms for Each of the Following Biological Agents 

Note: Data are from our 2002 survey of hospitals and their emergency departments. Responses were 

weighted to provide estimates for the universe of hospitals. 

About half of all hospitals reported participating in drills or tabletop 

exercises simulating a biological attack during the past 2 years.24 Hospitals 

that reported participating in biological drills were on average around 20 

percent larger than hospitals that did not. Of all of the hospitals that 

participated in biological drills or exercises, approximately 80 percent 

carried out these activities with other organizations. 

The availability of medical equipment needed for bioterrorism response 

varied greatly among hospitals, and hospitals reported that they did not 

have the capacity to respond to the large increase in the number of 

patients that would be likely to result from a bioterrorist incident with 

mass casualties (see table 2). For example, if a large number of patients 

were to arrive at a hospital with severe respiratory problems associated 

with anthrax or botulism, a comparable number of ventilators would be 

required to treat them. However, half of the hospitals had, per 100 staffed 

 24A tabletop exercise is a type of simulation in which participants discuss scenarios and 

responses around a table or similar setting. 

Hospitals Reported 

Insufficient Medical 

Equipment to Handle a 

Large Increase in Patients 

93.0

80.9

80.8

71.8

71.2

Smallpox 87.9

Anthrax

Plague

Botulism

Tularemia

Hemorrhagic

fever viruses

Percentage of hospitals

Source: GAO.

0 20 40 60 80 100
Page 15 GAO-03-924 Hospital Bioterrorism Preparedness 

beds, fewer than six ventilators, three or fewer personal protective 

equipment (PPE) suits, fewer than four isolation beds, or the ability to 

handle fewer than six patients per hour through a 5-minute 

decontamination shower. More specifically, fewer than 31 percent of 

hospitals could handle 10 or more patients per hour through a 5-minute 

decontamination shower per 100 staffed beds, and fewer than 10 percent 

had 10 or more isolation beds per 100 staffed beds. Almost 40 percent of 

the hospitals had fewer than two PPE suits per 100 staffed beds, and 

almost 10 percent had fewer than two ventilators per 100 staffed beds. 

Hospital officials have told us that bioterrorism preparedness is expensive 

and they are reluctant to create capacity that is not needed on a routine 

basis and may never be needed at a particular facility.25

Table 2: Urban Hospitals with Medical Equipment Capabilities, per 100 Staffed Beds 

Percentage of 

hospitals 

Ventilators 

Less than 2 ventilators 9.0 

2 to less than 5 ventilators 33.9 

5 to less than 10 ventilators 39.7 

10 or more ventilators 17.4 

Total percentage of hospitals 100 

Personal protective equipment (PPE) suits 

Less than 2 PPE suits 38.2 

2 to less than 5 PPE suits 24.8 

5 to less than 10 PPE suits 16.6 

10 or more PPE suits 20.3 

Total percentage of hospitals 100a

Isolation beds 

Less than 2 isolation beds 18.6 

2 to less than 5 isolation beds 47.3 

5 to less than 10 isolation beds 24.6 

10 or more isolation beds 9.5 

Total percentage of hospitals 100 

 25GAO-03-373. 
Page 16 GAO-03-924 Hospital Bioterrorism Preparedness 

Percentage of 

hospitals 

Number of patients per hour through 5 minute decontamination shower 

Less than 2 patients per hour 15.3 

2 to less than 5 patients per hour 25.8 

5 to less than 10 patients per hour 28.4 

10 or more patients per hour 30.5 

Total percentage of hospitals 100 

Source: GAO. 

Note: Data are from our 2002 survey of hospitals and their emergency departments. Responses were 

weighted to provide estimates for the universe of hospitals. 

a

Does not total to 100 percent due to rounding. 

As concerns about bioterrorism have intensified over the past few years, 

hospitals across the nation have been working to increase their 

preparedness for responding to such events. The staff and equipment that 

hospitals would require to respond to a bioterrorist attack with mass 

casualties are far greater than what are needed for everyday performance. 

Meeting those needs fully could be extremely difficult because 

bioterrorism preparedness is expensive and hospitals are reluctant to 

create capacity that is not needed on a routine basis and may never be 

used. In addition, along with a hospital’s ability to meet the routine needs 

of the community, needs for additional capacity for responding to 

bioterrorism emergencies must be balanced with the need to be prepared 

for all types of emergencies. Hospital officials have recognized that their 

facilities are an essential component of our nation’s bioterrorism 

preparedness and have begun planning and training efforts to increase 

their response capacity. Most hospitals, however, still lack equipment, 

medical stockpiles, and quarantine and isolation facilities for even a smallscale response. The additional funding that is to be provided under the 

National Bioterrorism Hospital Preparedness Program in fiscal year 2003 

can be used to help hospitals address these issues. The additional 

guidance from HHS, in response to our earlier recommendations, may also 

be helpful in assisting hospitals to better determine what specific response 

capacities they need to ensure. 

Concluding 

Observations 
Page 17 GAO-03-924 Hospital Bioterrorism Preparedness 

Representatives from the American Hospital Association provided oral 

comments on a draft of this report. The officials generally agreed with our 

findings and stated that this was a good and useful report providing 

helpful information on hospital preparedness. They commended us for the 

high response rate to the survey, stating that this provided a more 

comprehensive picture of hospital activities than was available elsewhere. 

The officials suggested that the report make greater reference to the lack 

of specific benchmarks for hospitals to use in planning, provide additional 

context on the range of possible events that hospitals must consider in 

their planning, and refer readers more specifically to prior GAO 

recommendations on bioterrorism preparedness. We have added 

additional material to clarify these points. The officials also provided 

technical remarks, which we have incorporated where appropriate. 

We are sending copies of this report to the Secretary of HHS, the 

Administrator of HRSA, and other interested officials. We will also provide 

copies to others upon request. In addition, the report will be available at 

no charge on GAO’s Web site at http://www.gao.gov. 

If you or your staffs have any questions about this report, please call me at 

(202) 512-7119. Key contributors are listed in appendix III. 

Marcia Crosse 

Acting Director, Health Care—Public 

 Health and Science Issues 

Comments from the 

American Hospital 

Association 
Page 18 GAO-03-924 Hospital Bioterrorism Preparedness 

List of Committees 

The Honorable Judd Gregg 

Chairman 

The Honorable Edward M. Kennedy 

Ranking Minority Member 

Committee on Health, Education, Labor, and Pensions 

United States Senate 

The Honorable Ted Stevens 

Chairman 

The Honorable Robert C. Byrd 

Ranking Minority Member 

Committee on Appropriations 

United States Senate 

The Honorable W.J. “Billy” Tauzin 

Chairman 

The Honorable John D. Dingell 

Ranking Minority Member 

Committee on Energy and Commerce 

House of Representatives 

The Honorable C.W. Bill Young 

Chairman 

The Honorable David Obey 

Ranking Minority Member 

Committee on Appropriations 

House of Representatives 
Appendix I: Selected Results of GAO Survey 

of Hospitals Regarding Hospital Preparedness 

for Bioterrorism 

Page 19 GAO-03-924 Hospital Bioterrorism Preparedness 

This appendix describes the characteristics of the short-term, nonfederal, 

general medical and surgical hospitals in metropolitan statistical areas 

(MSA) in the United States that had emergency departments in 2000 that 

we surveyed, and summarizes results by state. We sent the questionnaires 

to 2,041 hospitals that met these criteria—20 did not have emergency 

departments in fiscal year 2001 or were closed, for a total of 2,021 

hospitals. We obtained responses to the survey from 1,489 hospitals, for an 

overall response rate of about 74 percent. However, 7 of these hospitals 

did not return the section of the survey addressing emergency 

preparedness, leaving 1,482, for a response rate of about 73 percent for the 

questions of concern for the current report. We weighted responses to 

adjust for a lower response rate from investor-owned (for-profit) hospitals 

to provide estimates representative of the entire universe of 2,021 

hospitals in MSAs. 

The following tables show selected survey information on the 

characteristics of the survey universe (table 3), response rates for 

hospitals by state for all states and the District of Columbia (table 4), 

planning and coordination activities (tables 5 through 8), and training 

activities (tables 9 and 10), for states that had at least 10 hospitals respond 

and a response rate of at least 50 percent (tables 4-10). All data in tables 

are weighted to provide estimates for the universe of 2,021 hospitals in 

MSAs. 

Appendix I: Selected Results of GAO Survey 

of Hospitals Regarding Hospital 

Preparedness for Bioterrorism 
Appendix I: Selected Results of GAO Survey 

of Hospitals Regarding Hospital Preparedness 

for Bioterrorism 

Page 20 GAO-03-924 Hospital Bioterrorism Preparedness 

Table 3: Characteristics of Hospitals in Survey 

 Number of hospitals Percentage

Population of hospital’s MSA 

2.5 million or more 545 27

1 million to less than 2.5 million 584 29

Less than 1 million 892 44

Total number of hospitals 2,021 100

Ownership type 

Private, not-for-profit 1,460 72

Investor-owned (for-profit) 311 15

Public (nonfederal) 250 12

Total number of hospitals 2,021 100

Teaching hospital 

Yes 713 35

No 1,308 65

Total number of hospitals 2,021 100

Number of staffed bedsa

Less than 100 331 16

100 to less than 200 617 31

200 to less than 300 453 22

300 or more 620 31

Total number of hospitals 2,021 100

Source: GAO. 

Note: Data are from our 2002 survey of hospitals and their emergency departments. Responses were 

weighted to provide estimates for the universe of hospitals. Percentages may not total 100 owing to 

rounding. 

a

Staffed beds are total facility beds set up and staffed at the end of the reporting period as reported by 

hospitals in the American Hospital Association Annual Survey Database 2000. 
Appendix I: Selected Results of GAO Survey 

of Hospitals Regarding Hospital Preparedness 

for Bioterrorism 

Page 21 GAO-03-924 Hospital Bioterrorism Preparedness 

Table 4: Number of Hospitals That Were Sent Survey, Number That Responded to 

Survey, and Percentage of Hospitals That Responded to Survey, by State and 

District of Columbia 

State 

Number of 

hospitals that were 

sent surveys

Number of hospitals 

that responded 

to survey 

Percentage of 

hospitals that 

responded to survey 

Alabama 34 24 71 

Alaska 3 2 67 

Arizona 27 19 70 

Arkansas 21 15 71 

California 173 109 63 

Colorado 25 19 76 

Connecticut 24 21 88 

Delaware 1 1 100 

DC 7 6 86 

Florida 129 89 69 

Georgia 58 41 71 

Hawaii 6 4 67 

Idaho 5 5 100 

Illinois 106 83 78 

Indiana 52 42 81 

Iowa 20 13 65 

Kansas 19 12 63 

Kentucky 26 21 81 

Louisiana 58 28 48 

Maine 7 5 71 

Maryland 36 26 72 

Massachusetts 44 37 84 

Michigan 74 53 72 

Minnesota 33 25 76 

Mississippi 16 12 75 

Missouri 57 37 65 

Montana 3 2 67 

Nebraska 9 8 89 

Nevada 5 4 80 

New Hampshire 9 7 78 

New Jersey 60 48 80 

New Mexico 10 6 60 
Appendix I: Selected Results of GAO Survey 

of Hospitals Regarding Hospital Preparedness 

for Bioterrorism 

Page 22 GAO-03-924 Hospital Bioterrorism Preparedness 

State 

Number of 

hospitals that were 

sent surveys

Number of hospitals 

that responded 

to survey 

Percentage of 

hospitals that 

responded to survey 

New York 125 94 75 

North Carolina 39 31 79 

North Dakota 4 3 75 

Ohio 96 71 74 

Oklahoma 24 16 67 

Oregon 23 19 83 

Pennsylvania 117 93 79 

Rhode Island 9 4 44 

South Carolina 32 24 75 

South Dakota 5 4 80 

Tennessee 40 36 90 

Texas 189 134 71 

Utah 18 14 78 

Vermont 2 2 100 

Virginia 40 33 83 

Washington 33 26 79 

West Virginia 15 11 73 

Wisconsin 51 41 80 

Wyoming 2 2 100 

Source: GAO. 
Appendix I: Selected Results of GAO Survey 

of Hospitals Regarding Hospital Preparedness 

for Bioterrorism 

Page 23 GAO-03-924 Hospital Bioterrorism Preparedness 

Table 5: Percentage of Urban Hospitals with a Written Emergency Response Plan 

Addressing Bioterrorism, by State 

State Percentage of hospitals 

Alabama 80.9 

Arizona 89.9 

Arkansas 100.0 

California 88.9 

Colorado 89.2 

Connecticut 85.7 

Florida 90.4 

Georgia 85.2 

Illinois 81.4 

Indiana 85.3 

Iowa 76.9 

Kansas 66.7 

Kentucky 90.1 

Maryland 80.8 

Massachusetts 88.9 

Michigan 78.0 

Minnesota 68.0 

Mississippi 91.8 

Missouri 77.3 

New Jersey 93.5 

New York 74.1 

North Carolina 80.0 

Ohio 81.7 

Oklahoma 79.6 

Oregon 71.1 

Pennsylvania 77.0 

South Carolina 83.3 

Tennessee 83.2 

Texas 74.2 

Utah 93.5 

Virginia 73.8 

Washington 84.8 
Appendix I: Selected Results of GAO Survey 

of Hospitals Regarding Hospital Preparedness 

for Bioterrorism 

Page 24 GAO-03-924 Hospital Bioterrorism Preparedness 

State Percentage of hospitals 

West Virginia 63.0 

Wisconsin 78.0 

Source: GAO. 

Note: Responses were weighted to provide estimates for the universe of hospitals. Data are 

presented for states that had at least 10 hospitals respond to survey and a response rate of at least 

50 percent. 
Appendix I: Selected Results of GAO Survey 

of Hospitals Regarding Hospital Preparedness 

for Bioterrorism 

Page 25 GAO-03-924 Hospital Bioterrorism Preparedness 

Table 6: Percentage of Urban Hospitals That Reported Specifying in Emergency Response Plan to Contact the Specified 

Entities during an Emergency, by State 

State 

Law 

enforcement Fire EMS HAZMAT 

Other 

hospitals

Public 

health 

agencies 

Other state 

and local 

government 

agencies 

Other 

laboratories 

Public 

private 

utilities 

Alabama 94.5 89.0 89.0 89.0 89.0 81.9 94.5 48.8 63.3 

Arizona 100.0 100.0 94.4 81.6 94.4 94.4 83.2 74.1 81.6 

Arkansas 93.7 93.7 93.7 87.4 93.7 93.7 87.4 40.4 85.6 

California 94.1 92.9 96.4 89.9 86.3 97.2 85.8 45.8 70.0 

Colorado 93.5 94.0 68.1 94.0 87.9 100.0 94.0 45.8 80.4 

Connecticut 100.0 100.0 100.0 100.0 100.0 94.4 77.8 70.6 83.3 

Florida 95.9 97.3 94.7 95.9 91.4 93.9 97.0 58.8 73.0 

Georgia 93.7 100.0 96.5 94.5 89.8 90.9 93.5 64.1 78.6 

Illinois 92.5 88.1 92.6 84.6 94.1 94.1 78.8 58.5 66.2 

Indiana 91.4 94.3 94.3 91.1 91.4 94.3 91.1 60.2 79.9 

Iowa 90.0 90.0 90.0 90.0 90.0 80.0 80.0 80.0 100.0 

Kansas 100.0 100.0 100.0 100.0 87.5 100.0 100.0 62.5 87.5 

Kentucky 89.1 83.6 83.6 76.6 83.6 89.1 100.0 61.7 67.2 

Maryland 100.0 95.2 100.0 90.5 81.0 100.0 95.2 57.1 85.0 

Massachusetts 100.0 96.8 96.8 96.8 77.4 100.0 93.3 71.0 80.6 

Michigan 92.1 100.0 88.9 89.5 92.1 97.4 92.3 62.2 81.6 

Minnesota 100.0 100.0 100.0 94.1 94.1 94.1 76.5 41.2 56.3 

Mississippi 91.0 91.0 100.0 70.5 100.0 100.0 100.0 67.6 70.5 

Missouri 82.3 89.4 88.4 81.3 84.3 88.4 81.3 46.0 70.7 

New Jersey 97.7 95.3 95.3 95.3 90.7 88.1 90.7 61.9 86.0 

New York 100.0 100.0 95.1 91.8 86.1 98.5 95.6 58.9 70.1 

North Carolina 95.8 95.8 91.7 83.3 87.5 87.0 91.7 47.6 82.6 

Ohio 96.4 92.7 94.5 90.9 94.4 94.5 92.7 57.7 81.5 

Oklahoma 92.2 92.2 92.2 92.2 100.0 100.0 92.2 81.6 92.2 

Oregon 75.6 75.6 75.6 100.0 67.4 100.0 67.4 34.9 59.3 

Pennsylvania 92.7 97.1 95.7 95.7 86.8 95.6 95.7 58.0 80.0 

South Carolina 100.0 93.0 100.0 93.0 100.0 93.9 100.0 38.3 87.8 

Tennessee 100.0 90.4 93.6 89.5 90.4 100.0 96.8 75.7 74.9 

Texas 90.0 90.4 90.3 88.3 80.3 90.6 86.8 56.2 76.3 

Utah 100.0 100.0 91.1 100.0 93.1 100.0 84.2 34.0 84.2 

Virginia 96.1 92.1 100.0 88.2 100.0 95.9 92.1 64.9 81.3 

Washington 91.0 91.0 86.5 86.5 95.3 100.0 85.9 53.3 53.3 
Appendix I: Selected Results of GAO Survey 

of Hospitals Regarding Hospital Preparedness 

for Bioterrorism 

Page 26 GAO-03-924 Hospital Bioterrorism Preparedness 

State 

Law 

enforcement Fire EMS HAZMAT 

Other 

hospitals

Public 

health 

agencies 

Other state 

and local 

government 

agencies 

Other 

laboratories 

Public 

private 

utilities 

West Virginia 100.0 100.0 100.0 100.0 100.0 86.3 100.0 63.7 54.9 

Wisconsin 96.8 96.8 90.3 93.5 87.5 90.0 90.6 45.2 65.6 

Source: GAO. 

Note: Responses were weighted to provide estimates for the universe of hospitals. Data are 

presented for states that had at least 10 hospitals respond to survey and a response rate of at least 

50 percent. 
Appendix I: Selected Results of GAO Survey 

of Hospitals Regarding Hospital Preparedness 

for Bioterrorism 

Page 27 GAO-03-924 Hospital Bioterrorism Preparedness 

Table 7: Percentage of Urban Hospitals Whose Mass Casualty Plans Address Bioterrorism and Describe How to Manage the 

Specified Function, by State 

State 

Decontamination 

of victims 

Mass 

patient 

Worried 

well 

Mass 

fatality

Mass 

evacuation 

Obtaining 

additional 

pharmaceuticals

Obtaining 

additional 

staff for 

surge 

capacity 

Obtaining 

additional 

other 

supplies 

for surge 

capacity 

Hospital 

security 

Alabama 100.0 94.5 76.3 68.5 92.9 94.2 100.0 94.5 100.0 

Arizona 88.8 100.0 69.3 76.0 92.4 92.4 100.0 84.8 92.4 

Arkansas 87.4 93.7 85.6 66.7 93.3 93.7 100.0 93.7 100.0 

California 94.7 95.5 82.9 75.3 95.6 91.1 97.9 97.8 98.9 

Colorado 100.0 100.0 81.9 86.2 87.9 94.0 91.8 100.0 100.0 

Connecticut 100.0 100.0 88.9 66.7 100.0 88.9 94.4 94.4 100.0 

Florida 95.0 95.5 69.7 77.6 88.9 98.5 98.8 100.0 100.0 

Georgia 94.5 97.2 84.2 79.9 86.9 86.2 93.7 91.5 96.5 

Illinois 97.0 98.5 77.6 77.3 91.0 97.0 97.0 97.0 100.0 

Indiana 94.1 94.3 78.5 79.9 85.7 77.0 97.1 94.3 94.3 

Iowa 100.0 100.0 80.0 100.0 90.0 100.0 100.0 100.0 100.0 

Kansas 100.0 87.5 71.4 75.0 100.0 87.5 87.5 87.5 100.0 

Kentucky 89.1 100.0 83.6 100.0 94.5 100.0 100.0 94.5 100.0 

Maryland 100.0 100.0 95.0 95.0 94.4 100.0 100.0 100.0 100.0 

Massachusetts 96.9 93.8 77.4 75.0 87.5 81.3 100.0 87.5 100.0 

Michigan 92.3 94.9 66.7 65.8 87.2 73.7 92.3 89.7 94.9 

Minnesota 76.5 88.2 52.9 52.9 64.7 94.1 100.0 94.1 100.0 

Mississippi 79.5 100.0 79.5 82.0 91.0 100.0 91.0 91.0 91.0 

Missouri 96.5 96.5 80.6 78.8 89.4 82.3 96.5 82.3 96.5 

New Jersey 100.0 93.0 65.9 75.0 90.7 97.7 93.0 95.3 100.0 

New York 91.1 98.5 77.1 65.4 92.4 80.2 97.0 92.2 98.5 

North Carolina 95.8 87.5 62.5 58.3 79.2 72.7 91.7 75.0 95.8 

Ohio 100.0 96.4 75.9 81.8 94.4 83.6 96.4 92.7 98.2 

Oklahoma 100.0 100.0 90.8 91.6 88.9 91.6 100.0 100.0 100.0 

Oregon 100.0 100.0 100.0 91.9 100.0 91.9 83.7 91.9 100.0 

Pennsylvania 94.2 94.3 71.8 59.3 90.0 82.3 95.7 92.9 100.0 

South Carolina 100.0 100.0 78.7 90.7 95.3 100.0 100.0 100.0 100.0 

Tennessee 93.6 96.8 79.8 86.2 96.8 90.4 93.6 93.6 92.7 

Texas 89.8 98.1 74.8 77.4 88.1 74.5 91.2 86.9 97.1 

Utah 100.0 100.0 100.0 100.0 100.0 77.2 93.1 91.1 100.0 

Virginia 91.0 91.0 82.0 75.3 91.0 87.1 96.1 95.0 95.0 
Appendix I: Selected Results of GAO Survey 

of Hospitals Regarding Hospital Preparedness 

for Bioterrorism 

Page 28 GAO-03-924 Hospital Bioterrorism Preparedness 

State 

Decontamination 

of victims 

Mass 

patient 

Worried 

well 

Mass 

fatality

Mass 

evacuation 

Obtaining 

additional 

pharmaceuticals

Obtaining 

additional 

staff for 

surge 

capacity 

Obtaining 

additional 

other 

supplies 

for surge 

capacity 

Hospital 

security 

Washington 100.0 86.5 73.1 73.1 91.0 86.5 100.0 86.5 100.0 

West Virginia 100.0 100.0 68.7 86.3 86.3 86.3 100.0 86.3 100.0 

Wisconsin 100.0 96.9 70.0 84.4 93.8 75.0 93.8 87.5 100.0 

Source: GAO. 

Note: Responses were weighted to provide estimates for the universe of hospitals. Data are 

presented for states that had at least 10 hospitals respond to survey and a response rate of at least 

50 percent. 
Appendix I: Selected Results of GAO Survey 

of Hospitals Regarding Hospital Preparedness 

for Bioterrorism 

Page 29 GAO-03-924 Hospital Bioterrorism Preparedness 

Table 8: Percentage of Urban Hospitals That Had Agreements with Other Hospitals 

or City, County, State, and Regional Organizations to Provide or Share Resources 

in the Event of Bioterrorism, by State 

State Hospitals City County State Regional

Alabama 73.1 51.1 45.5 35.7 30.8

Arizona 73.1 52.8 58.5 21.1 21.1

Arkansas 75.6 70.8 52.7 48.6 35.4

California 55.5 36.8 58.9 33.6 32.2

Colorado 74.4 43.8 38.3 21.9 32.8

Connecticut 45.0 57.9 14.3 33.3 35.3

Florida 75.8 49.8 64.5 39.3 34.7

Georgia 76.3 55.1 62.6 38.4 42.9

Illinois 61.0 55.2 45.6 55.6 49.3

Indiana 70.8 60.5 68.5 41.5 34.4

Iowa 84.6 72.7 72.7 50.0 40.0

Kansas 58.3 44.4 54.5 33.3 40.0

Kentucky 76.5 58.5 67.2 14.0 34.7

Maryland 52.4 33.3 66.7 43.8 43.8

Massachusetts 50.0 57.1 21.9 34.4 45.5

Michigan 73.6 53.1 70.0 40.0 57.4

Minnesota 72.7 42.9 47.6 35.0 35.0

Mississippi 84.8 48.2 48.2 45.9 48.2

Missouri 70.7 54.2 39.6 27.7 39.6

New Jersey 73.3 42.9 59.5 38.5 31.6

New York 58.7 27.6 44.3 21.1 20.8

North Carolina 64.5 35.5 45.2 33.3 43.3

Ohio 82.4 68.3 71.3 45.8 46.6

Oklahoma 92.0 83.5 83.5 69.1 64.5

Oregon 88.2 65.6 57.9 18.4 40.5

Pennsylvania 60.6 39.2 52.1 26.1 41.5

South Carolina 91.1 69.6 81.6 69.7 41.0

Tennessee 82.5 72.8 72.8 58.7 39.5

Texas 57.2 40.5 31.5 17.1 24.2

Utah 82.6 45.9 45.9 50.0 53.6

Virginia 93.8 59.2 59.2 50.3 84.6

Washington 92.4 73.1 76.5 50.7 43.6
Appendix I: Selected Results of GAO Survey 

of Hospitals Regarding Hospital Preparedness 

for Bioterrorism 

Page 30 GAO-03-924 Hospital Bioterrorism Preparedness 

State Hospitals City County State Regional

West Virginia 91.4 71.6 65.4 45.7 25.9

Wisconsin 62.2 44.4 48.6 16.7 24.1

Source: GAO. 

Note: Responses were weighted to provide estimates for the universe of hospitals. Data are 

presented for states that had at least 10 hospitals respond to survey and a response rate of at least 

50 percent. 
Appendix I: Selected Results of GAO Survey 

of Hospitals Regarding Hospital Preparedness 

for Bioterrorism 

Page 31 GAO-03-924 Hospital Bioterrorism Preparedness 

Table 9: Percentage of Urban Hospitals That Have Provided Training to Staff (Services, Courses, or Self-Learning Materials) 

to Identify and Diagnose Symptoms for the Following Biological Agents, by State 

State Smallpox Anthrax Plague Botulism Tularemia Hemorrhagic fever viruses 

Alabama 88.2 92.1 79.2 71.3 62.4 71.3 

Arizona 73.4 78.4 73.4 73.4 68.3 73.4 

Arkansas 93.7 93.7 79.3 87.4 79.3 73.0 

California 89.2 91.0 87.4 86.5 82.8 84.6 

Colorado 84.7 89.8 79.6 73.0 67.9 73.0 

Connecticut 85.7 95.2 81.0 85.0 80.0 70.0 

Florida 86.2 94.3 74.2 78.2 65.7 69.1 

Georgia 88.5 100.0 88.5 88.5 86.2 83.2 

Illinois 95.2 96.4 78.5 83.7 72.7 73.4 

Indiana 81.6 89.8 76.7 74.3 63.9 62.2 

Iowa 92.3 92.3 76.9 84.6 66.7 83.3 

Kansas 83.3 91.7 66.7 66.7 66.7 58.3 

Kentucky 90.1 100.0 90.1 90.1 85.2 80.3 

Maryland 88.5 96.2 84.6 84.6 84.0 80.0 

Massachusetts 89.2 91.9 77.1 75.0 75.0 71.4 

Michigan 88.7 92.5 81.1 79.2 64.7 65.4 

Minnesota 91.7 91.7 82.6 87.0 65.2 59.1 

Mississippi 92.4 92.4 92.4 92.4 92.4 82.6 

Missouri 83.3 91.3 70.0 70.0 70.0 67.3 

New Jersey 97.8 100.0 95.6 95.5 86.4 86.4 

New York 89.3 94.6 87.8 85.0 76.3 77.9 

North Carolina 87.1 93.5 77.4 77.4 64.5 58.1 

Ohio 88.8 91.6 84.6 77.6 65.9 67.3 

Oklahoma 87.6 93.8 87.6 87.6 76.8 78.3 

Oregon 94.2 94.5 76.9 82.6 69.4 63.6 

Pennsylvania 87.0 91.3 82.3 82.3 74.2 72.5 

South Carolina 96.1 96.1 76.0 76.0 52.5 42.7 

Tennessee 91.0 93.7 85.5 82.0 78.6 78.6 

Texas 83.1 92.5 75.9 77.0 64.6 62.5 

Utah 85.2 100.0 85.2 85.2 85.2 85.2 

Virginia 85.5 85.5 85.0 78.2 64.1 60.0 

Washington 84.8 92.4 77.2 77.2 65.8 69.6 
Appendix I: Selected Results of GAO Survey 

of Hospitals Regarding Hospital Preparedness 

for Bioterrorism 

Page 32 GAO-03-924 Hospital Bioterrorism Preparedness 

State Smallpox Anthrax Plague Botulism Tularemia Hemorrhagic fever viruses 

West Virginia 90.5 100.0 90.5 78.4 78.4 68.9 

Wisconsin 92.5 95.0 82.5 87.5 72.5 72.5 

Source: GAO. 

Note: Responses were weighted to provide estimates for the universe of hospitals. Data are 

presented for states that had at least 10 hospitals respond to survey and a response rate of at least 

50 percent. 
Appendix I: Selected Results of GAO Survey 

of Hospitals Regarding Hospital Preparedness 

for Bioterrorism 

Page 33 GAO-03-924 Hospital Bioterrorism Preparedness 

Table 10: Percentage of Urban Hospitals That Participated in Mass Casualty Drills 

Related to Biological Incidents by State 

State Percentage of hospitals 

Alabama 54.5 

Arizona 36.7 

Arkansas 41.4 

California 57.3 

Colorado 35.8 

Connecticut 47.6 

Florida 58.4 

Georgia 44.6 

Illinois 38.3 

Indiana 61.6 

Iowa 53.8 

Kansas 41.7 

Kentucky 57.7 

Maryland 38.5 

Massachusetts 35.1 

Michigan 43.4 

Minnesota 32.0 

Mississippi 65.2 

Missouri 39.9 

New Jersey 50.0 

New York 33.6 

North Carolina 45.2 

Ohio 66.3 

Oklahoma 51.7 

Oregon 48.1 

Pennsylvania 39.7 

South Carolina 33.3 

Tennessee 40.1 

Texas 44.2 

Utah 60.2 

Virginia 70.9 

Washington 54.3 
Appendix I: Selected Results of GAO Survey 

of Hospitals Regarding Hospital Preparedness 

for Bioterrorism 

Page 34 GAO-03-924 Hospital Bioterrorism Preparedness 

State Percentage of hospitals 

West Virginia 17.3 

Wisconsin 48.8 

Source: GAO. 

Note: Responses were weighted to provide estimates for the universe of hospitals. Data are 

presented for states that had at least 10 hospitals respond to survey and a response rate of at least 

50 percent. 
Appendix II: Scope and Methodology 

Page 35 GAO-03-924 Hospital Bioterrorism Preparedness 

Between May and September 2002 we surveyed more than 2,000 shortterm,1

 nonfederal, general medical and surgical hospitals with emergency 

departments located in metropolitan statistical areas (MSAs).2

 Survey 

hospitals were located in the 50 states and the District of Columbia. 

The survey questionnaire contained three parts. The first and second parts 

addressed emergency room functioning, and the third part addressed 

hospital preparedness for bioterrorism. We reported our survey findings 

on emergency room functioning in March 2003.3

 We conducted our work 

between May 2002 and July 2003 in accordance with generally accepted 

government auditing standards. 

Of the initial universe of 2,041 hospitals that met the selection criteria, 

18 had closed by 2002 and 2 did not have emergency departments in fiscal 

year 2001, resulting in a final universe of 2,021 hospitals. We sent our 

questionnaire to these hospitals and conducted follow-up mailings and 

telephone follow-up calls to nonrespondents. We obtained responses to 

the survey from 1,489 hospitals, for an overall response rate of about 74 

percent. However, 7 of these hospitals did not return the section of the 

survey addressing emergency preparedness, leaving 1,482, for a response 

rate of about 73 percent for the questions of concern for the current 

report.4

We analyzed the response rates by hospital size, type of ownership, and 

teaching status to assess if there was differential response among various 

categories of hospitals. The only statistically significant disproportionate 

response was from for-profit hospitals. Therefore we weighted responses 

to adjust for a lower response rate from investor-owned (for-profit) 

hospitals to provide estimates representative of the entire universe of 

2,021 hospitals in MSAs. Using the information provided by surveyed 

hospitals, we described the extent of emergency preparedness for 

 1

We excluded federal hospitals, specialty hospitals, long-term care facilities, and hospitals 

located outside the 50 states or the District of Columbia. 

2

We focused on hospitals located in metropolitan areas designated as MSAs and Primary 

MSAs by the U.S. Census Bureau. For purposes of this report, we will refer to both types of 

areas as MSAs. In 2000, about 80 percent of the nation’s population lived in MSAs. 

3

U.S. General Accounting Office, Hospital Emergency Departments: Crowded Conditions 

Vary among Hospitals and Communities, GAO-03-460 (Washington, D.C.: Mar. 14, 2003). 

4

Questionnaires received after September 3, 2002, were not included in calculating our 

response rate and were excluded from our analyses. 

Appendix II: Scope and Methodology 
Appendix II: Scope and Methodology 

Page 36 GAO-03-924 Hospital Bioterrorism Preparedness 

bioterrorist incidents. We also examined the relationships between the 

extent of hospital bioterrorism preparedness and size of hospital as 

indicated by the number of inpatient staffed beds. 

Questions in the survey focused on preparedness to respond to a 

bioterrorist event. Some of the responses are applicable more broadly to 

preparedness for all types of terrorist events, as well as for natural 

disasters or naturally occurring disease outbreaks. However, because the 

focus of this work was bioterrorism preparedness, we did not ask more 

detailed questions on other types of preparedness. 
Appendix III: GAO Contact and Staff 

Acknowledgments 

Page 37 GAO-03-924 Hospital Bioterrorism Preparedness 

Marcia Crosse, (202) 512-7119 

In addition to the contact named above, George Bogart, Jennifer Cohen, 

Robert Copeland, Susan Lawes, Deborah Miller, and Roseanne Price made 

key contributions to this report. 

Appendix III: GAO Contact and Staff 

Acknowledgments 

GAO Contact 

Acknowledgments 
Related GAO Products 

Page 38 GAO-03-924 Hospital Bioterrorism Preparedness 

Severe Acute Respiratory Syndrome: Established Infectious Disease 

Control Measures Helped Contain Spread, but a Large-Scale Resurgence 

May Pose Challenges. GAO-03-1058T. Washington, D.C.: July 30, 2003.

Bioterrorism: Information Technology Strategy Could Strengthen 

Federal Agencies’ Abilities to Respond to Public Health Emergencies. 

GAO-03-139. Washington, D.C.: May 30, 2003. 

SARS Outbreak: Improvements to Public Health Capacity Are Needed for 

Responding to Bioterrorism and Emerging Infectious Diseases. 

GAO-03-769T. Washington, D.C.: May 7, 2003. 

Smallpox Vaccination: Implementation of National Program Faces 

Challenges. GAO-03-578. Washington, D.C.: April 30, 2003. 

Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have 

Improved Public Health Response Capacity, but Gaps Remain. 

GAO-03-654T. Washington, D.C.: April 9, 2003. 

Bioterrorism: Preparedness Varied across State and Local Jurisdictions. 

GAO-03-373. Washington, D.C.: April 7, 2003. 

Hospital Emergency Departments: Crowded Conditions Vary among 

Hospitals and Communities. GAO-03-460. Washington, D.C.: 

March 14, 2003. 

Homeland Security: New Department Could Improve Coordination but 

Transferring Control of Certain Public Health Programs Raises 

Concerns. GAO-02-954T. Washington, D.C.: July 16, 2002. 

Homeland Security: New Department Could Improve Biomedical R&D 

Coordination but May Disrupt Dual-Purpose Efforts. GAO-02-924T. 

Washington, D.C.: July 9, 2002. 

Homeland Security: New Department Could Improve Coordination but 

May Complicate Priority Setting. GAO-02-893T. Washington, D.C.: 

June 28, 2002. 

Homeland Security: New Department Could Improve Coordination but 

May Complicate Public Health Priority Setting. GAO-02-883T. 

Washington, D.C.: June 25, 2002. 

Related GAO Products 
Related GAO Products 

Page 39 GAO-03-924 Hospital Bioterrorism Preparedness 

Bioterrorism: The Centers for Disease Control and Prevention’s Role in 

Public Health Protection. GAO-02-235T. Washington, D.C.: 

November 15, 2001. 

Bioterrorism: Review of Public Health Preparedness Programs. 

GAO-02-149T. Washington, D.C.: October 10, 2001. 

Bioterrorism: Public Health and Medical Preparedness. GAO-02-141T. 

Washington, D.C.: October 9, 2001. 

Bioterrorism: Coordination and Preparedness. GAO-02-129T. 

Washington, D.C.: October 5, 2001. 

Bioterrorism: Federal Research and Preparedness Activities. 

GAO-01-915. Washington, D.C.: September 28, 2001. 

West Nile Virus Outbreak: Lessons for Public Health Preparedness. 

GAO/HEHS-00-180. Washington, D.C.: September 11, 2000. 

Combating Terrorism: Need for Comprehensive Threat and Risk 

Assessments of Chemical and Biological Attacks. GAO/NSIAD-99-163. 

Washington, D.C.: September 14, 1999. 

Combating Terrorism: Observations on Biological Terrorism and Public 

Health Initiatives. GAO/T-NSIAD-99-112. Washington, D.C.: March 16, 

1999. 

(290269) 
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