Number 37 n March 24, 2011

Hospital Preparedness for Emergency Response: 

United States, 2008 Richard W. Niska, M.D., M.P.H.; and Iris M. Shimizu, Ph.D.

Abstract

Objective—This report is a summary of hospital preparedness for responding

to public health emergencies, including mass casualties and epidemics of

naturally occurring diseases such as influenza.

Methods—Data are from an emergency response preparedness supplement to

the 2008 National Hospital Ambulatory Medical Care Survey, which uses a

national probability sample of nonfederal general and short-stay hospitals in the

United States. Sample data were weighted to produce national estimates.

Key results

+ Nearly all hospitals had response plans for chemical releases, natural disasters,

epidemics, and biological incidents. Preparedness for explosive or incendiary

incidents was less frequent than preparedness for other types of incidents.

+ While most hospitals had plans for cancellation of elective procedures and

admissions, two-thirds had plans for alternate care areas with beds, staffing, and

equipment.

+ One-half of hospitals planned for alternate care areas in inpatient hallways or

decommissioned ward space, or for conversion of inpatient units to augment

intensive care.

+ One-half of hospitals had adjusted standards of care for allocation of mechanical

ventilators for mass casualties.

+ Although over one-half of hospitals had staged epidemic drills, only one-third

included mass vaccination or medication distribution.

+ One-half of hospitals planned for advance registration of health care

professionals.

+ While most hospitals had memoranda of understanding (MOUs) with other

hospitals to transfer adults during an epidemic, fewer hospitals had MOUs for

pediatrics and burns. Less than one-half of hospitals accommodated the needs of

children and persons with disabilities during a public health emergency.

Keywords: Emergency preparedness + hospital preparedness + mass casualty +

pandemic

Introduction

Following the World Trade Center

attack of September 2001 and the

anthrax terrorism incident of October

2001, there has been a heightened

interest in using surveys to assess our

readiness for various disasters.

Therefore, the U.S. Department of

Health and Human Services, Office of

the Assistant Secretary for Planning and

Evaluation (ASPE), provided funding to

the National Center for Health Statistics

(NCHS) to survey hospitals about

preparedness for treating patients from

bioterrorism attacks or mass casualty

incidents. Bioterrorism and Mass

Casualty Preparedness Supplements

were added to the 2003 and 2004

National Hospital Ambulatory Medical

Care Surveys (NHAMCS). A

preliminary report on hospital

preparedness for bioterrorism or other

mass casualties showed that hospitals

were prepared in 2003 in most of the

areas studied (1). Other more

comprehensive publications covering

both years followed (2–4).

In subsequent years, the national

focus shifted from bioterrorism to

preparation for natural disasters such as

Hurricane Katrina and major influenza

outbreaks. In 2004, an outbreak of

H5N1 avian influenza was reported in

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Disease Control and Prevention 

National Center for Health Statistics 
Page 2	 National Health Statistics Reports n Number 37 n March 24, 2011

poultry in nine eastern Asian countries,

which was genetically related to 52 fatal

human cases reported by early 2005 (5).

By the end of 2008, H5N1 avian

influenza had been responsible for 248

human deaths in 15 countries in Asia

and Africa, and had been reported in

both domestic and wild birds in Europe

as well (6,7). Although no avian or

human H5N1 cases have been reported

in the Americas, there is public concern

that this virus or others could result in

outbreaks or even pandemics in the

future. In response to this concern,

ASPE provided funds for NCHS to

survey hospitals on their preparedness

for mass casualty events including

pandemics.

This report serves as a descriptive

summary of hospital preparedness for

dealing with naturally occurring

diseases, epidemics and pandemics such

as influenza, and other public health

emergencies. Information about

emergency preparedness in U.S.

hospitals is crucial for those who are

charged with planning how to prevent

and treat large outbreaks of infectious

disease and other mass casualty events.

Methods

NHAMCS is a national annual

survey of ambulatory medical care visits

to noninstitutional, nonfederal, acute

care, and short-stay hospitals. Short-stay

hospitals are those with an average

length of stay of less than 30 days,

whereas acute care hospitals are those

whose specialty is general (medical or

surgical) or children’s general.

NHAMCS uses a multistage probability

sampling design involving samples of

geographic primary sampling units and

hospitals with emergency departments

(ED) or outpatient departments within

those units. The data are weighted using

the inverse probabilities of hospital

selection with an adjustment for

nonresponse. Therefore, estimates are

considered representative of hospitals

throughout the United States.

In 2008, emergency preparedness

items were added to NHAMCS in a

special supplement. Many of the items

on the 2003–2004 surveys were

retained, but the 2008 instrument was

greatly expanded to include new

questions arising from research findings

as well as those suggested by outside

professional organizations. This report

focuses on new content added to the

2008 survey. A future report will discuss

trends between 2003–2004 and 2008 for

items that were retained from the earlier

surveys.

NHAMCS is administered on-site at

each participating hospital by field

representatives employed by the U.S.

Census Bureau under an interagency

agreement with NCHS. The pandemic

supplement was an eight-page selfadministered questionnaire consisting of

112 total data items. It was completed

for each sample hospital by the person

responsible for the hospital’s emergency

response plan. The supplement was

returned to the U.S. Census Bureau’s

National Processing Center (NPC) with

the NHAMCS core materials. NPC

performed the quality control edits and

data entry, and provided NCHS with

monthly updates and a final cumulative

SAS file.

A descriptive analysis was

conducted by NCHS using a first-order

Taylor series approximation method as

applied in SUDAAN-9.0.1 to account

for the complex survey design (8).

Because all continuous variables had

positively skewed distributions, the

central tendency was reported as the

median.

The determination of statistical

significance was based on the two-tailed

t-test. The Bonferroni inequality was

used to establish the critical value for

statistically significant differences (0.05

level of significance) based on the

number of possible comparisons within

a particular variable (or combination of

variables) of interest. Terms relating to

differences such as ‘‘more’’ or ‘‘fewer’’

indicate that the difference is

statistically significant. Terms such as

‘‘not different’’ or ‘‘similar’’ indicate

that the difference is not statistically

significant. A lack of comment on a

particular difference does not imply

anything about statistical significance.

Results

Of the sample of 395 in-scope

hospitals from the 2008 NHAMCS, 294

hospitals responded to the supplement

(response rate of 74.4 percent

unweighted and 78.1 percent weighted),

representing the national weighted

universe of 5,212 hospitals.

Emergency response plans

+	 All hospitals had an emergency

response plan for at least one of the

six hazards studied (epidemicpandemic, biological, chemical,

nuclear-radiological, explosiveincendiary, and natural incidents)

(Table 1, Figure 1).

+	 Nearly all hospitals (99.0 percent) had

emergency response plans that

specifically addressed chemical

accidents or attacks, which were not

significantly different from the

prevalence of plans for natural

disasters (97.8 percent), epidemics or

pandemics (94.1 percent), and

biological accidents or attacks

(93.2 percent).

+ Significantly fewer hospitals

(81.3 percent) had plans for nuclear

or radiological accidents or attacks

than for chemical accidents or attacks

and natural disasters.

+ Significantly fewer hospitals

(79.6 percent) had plans for explosive

or incendiary accidents or attacks

than for chemical accidents or

attacks, natural disasters, epidemics

or pandemics, and biological

accidents or attacks.

+	 About 67.9 percent of hospitals had

plans for all six hazards.

Cooperative planning

+	 About 99.6 percent of hospitals

engaged in cooperative planning with

at least one of the eight entities

studied (Table 2).

+	 About 93.7 percent of hospitals

engaged in cooperative planning in

developing or updating an emergency

response plan for public health

emergencies with the state or local

office of emergency management; this

was not significantly different from

the prevalences for planning with

other hospitals (92.7 percent),

emergency medical services (EMS)

(89.0 percent), state or local public
 

National Health Statistics Reports n Number 37 n March 24, 2011	 Page 3

Chemical Natural Epidemic Biological 

Percent 

SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008. 

Incident type 

1NUC–RAD is nuclear-radiological. Significantly different from chemical and natural incidents (both p < 0.05). 

95% confidence interval 

0 

20 

40 

60 

80 

100

 NUC–RAD1 EXP–INC2 

2EXP–INC is explosive-incendiary. Significantly different from chemical, natural, epidemic, and biological incidents 

(all p < 0.05). 

99.0 97.8 94.1 93.2 81.3 79.6 

Figure 1. Percentage of hospitals with emergency response plans for selected types of

incidents: United States, 2008

health departments (88.7 percent), or

fire departments (86.0 percent).

+ Significantly fewer hospitals included

hazardous materials teams

(64.3 percent) or the Federal Bureau

of Investigation (19.0 percent) in their

emergency response planning than the

other six entities listed above.

+ About 18.7 percent of hospitals

included all eight entities in their

emergency response planning.

Plans for components of

hospital preparedness

Table 3 summarizes responses to a

series of questions about written

emergency response plans for 48

components of preparedness for hospital

overcrowding incidents or public health

emergencies, and whether the plans

were implemented in an actual incident

during 2007. Broad categories of

hospital preparedness included

memoranda of understanding (MOUs)

with other hospitals, regional

communication systems, mutual aid

agreements, expansion of on-site surge

capacity, priority setting for limited

resources, expansion of on-site health

care work force, mass casualty

management, management of pediatric

and other special populations, and

communication strategies.

MOUs with other hospitals

+	 About 87.8 percent of hospitals had

MOUs with one or more hospitals to

accept adult patients, but only

56.2 percent had MOUs with one or

more children’s hospitals to accept

pediatric patients in transfer from

their own ED when no beds were

available at the hospital.

+	 Only 8.6 percent of hospitals had

implemented adult transfer MOUs,

and 8.0 percent had implemented

pediatric transfer MOUs during actual

incidents in 2007.

+	 Only about one-half of hospitals had

MOUs with burn centers to accept

explosive-incendiary mass casualties

(56.9 percent), or with other

outpatient facilities to augment

outpatient services (42.8 percent).

Regional communication systems

+	 About 85.3 percent of hospitals had

regional communication systems to

track ED closures or diversions.

About 29.2 percent implemented

these systems during an actual

incident in 2007.

+	 About 80.6 percent of hospitals had

regional communication systems to

track available adult intensive care

unit (ICU) beds, 70.1 percent tracked

pediatric ICU beds, and 64.8 percent

tracked neonatal ICU beds. About

22.6 percent implemented adult ICU

tracking systems, 16.9 percent

implemented pediatric ICU tracking

systems, and 14.1 percent

implemented neonatal ICU tracking

systems during an actual incident in

2007.

+	 Most hospitals had regional

communication systems to track

available adult (89.7 percent),

pediatric (82.0 percent), and neonatal

(67.8 percent) hospital beds. About

one-quarter implemented adult

(30.4 percent), pediatric

(23.7 percent), or neonatal

(18.9 percent) bed tracking systems

during an actual incident in 2007.

+	 Only 51.9 percent of hospitals had

regional communication systems to

track specialty coverage. About

15.1 percent implemented this system

in 2007.

Mutual aid agreements

+	 About 84.1 percent of hospitals had

mutual aid agreements with other

agencies to share supplies and

equipment. About 16.3 percent

implemented these agreements in

2007.

Expansion of on-site surge

capacity

+	 About 90.5 percent of hospitals had

plans for isolation of airborne disease

patients in negative pressure rooms.

About 14.2 percent implemented

these plans in 2007 (Table 3,

Figure 2).

+	 About 86.3 percent of hospitals had

plans for cancellation of elective

procedures and admissions. About

12.9 percent implemented these plans

in 2007.

+	 About 73.7 percent of hospitals had

plans for setting up temporary

facilities when the hospital is

unusable (e.g., without power or

flooded).

+	 Many hospitals had plans for

establishment of alternate care areas

with beds, staffing, and equipment in

nonclinical space (68.7 percent),

inpatient unit hallways (52.3 percent),

or decommissioned ward space

(49.7 percent).
 

 

 

Page 4	 National Health Statistics Reports n Number 37 n March 24, 2011 Percent 

SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008. 

Component 

95% confidence interval 

0 

20 

40 

60 

80 

100 

50.7 49.7 

Elective 

cancellations 

Nonclinical 

space 

Inpatient

hallways 

Intensive 

care 

conversion 

Decommissioned 

ward space 

52.3 

68.7 

86.3 

Figure 2. Percentage of hospitals with plans for selected components of onsite surge

capacity expansion: United States, 2008

+ Only 50.7 percent of hospitals had

plans for conversion of inpatient units

to augment intensive care capacity.

Priority setting for limited

resources

+ About 72.4 percent of hospitals had

written triage processes for limited

intensive care resources (Table 3).

+ About 64.0 percent of hospitals had

plans for regional coordination of

adjusted standards of care during a

pandemic or other mass casualty

incident.

+ About 43.2 percent of hospitals had

plans for implementing adjusted

standards of care for initiation and

withdrawal of mechanical ventilation.

+ About 32.9 percent of hospitals had

plans for delivery of potassium iodide

in response to radioactive release.

Expanding on-site health care

work force

+ About 88.8 percent of hospitals had a

plan for continuity of operations in

the event of an emergency. About

14.9 percent implemented this plan

during an actual incident in 2007.

+ About 6 of 10 hospitals had mutual

aid agreements with other agencies to

share health care providers

(69.5 percent), or plans for advance

registration of volunteer health

professionals (55.9 percent).

+	 About 6 of 10 hospitals had plans for

staff absenteeism due to personal or

family impact from the emergency

(66.9 percent), or on-site child care to

maintain staff at the hospital

(63.1 percent).

Mass casualty management

+	 About 94.6 percent of hospitals had

plans for hospital evacuations.

+	 Most hospitals had plans for

transporting large numbers of patients

within the hospital (83.9 percent) or

between hospitals (77.0 percent).

+	 Only 62.6 percent of hospitals had

plans for an on-site large capacity

morgue.

Pediatrics

+	 About 42.6 percent of hospitals had a

tracking system for accompanied and

unaccompanied children.

+	 About 34.0 percent of hospitals had

plans for reunification of children

with families, and 31.1 percent for

protocols to identify and protect

displaced children.

+	 About 32.4 percent of hospitals had

guidelines for increasing pediatric

surge capacity.

+	 About 29.4 percent of hospitals had

plans for acquiring supplies to shelter

healthy displaced children.

Special populations

+	 About 73.3 percent of hospitals had

plans for communicating with

non-English-speaking patients. About

15.4 percent implemented those plans

during an actual incident in 2007.

+	 Only about one-half of hospitals had

plans for communicating with deaf

(58.3 percent) or blind (47.5 percent)

patients.

+	 About 47.6 percent of hospitals had

plans for sheltering mobility-impaired

patients.

+	 About 46.7 percent of hospitals had

plans for sheltering patients with

special health care needs. About

42.0 percent implemented these plans

during an actual incident in 2007.

+	 Only about one-third of hospitals had

plans for sheltering pregnant women

(39.2 percent), mentally challenged

(39.0 percent), or technologydependent (33.7 percent) patients.

Communications

+	 About 93.4 percent of hospitals had

plans for receiving notification of

alerts from the state or local health

department. About 34.5 percent

implemented these plans during an

actual incident in 2007.

+	 About 79.4 percent of hospitals had

plans for participating with local

public health departments in public

education about the importance of

influenza vaccination. About

29.5 percent implemented these plans

during an actual incident in 2007.

Internal mass casualty drills,

simulations, or exercises

+ In the last year, one-half

(50.6 percent) of hospitals conducted

more than one internal drill;

31.9 percent conducted only one

internal drill; 11.1 percent conducted

no internal drills; and the number of

internal drills was unknown for

6.4 percent (Tables 4 and 5).

+	 For those hospitals in which the

number of drills was known, the

median number of internal full-scale

simulations conducted was one.

+	 The median number of adult victims

utilized in each hospital’s largest

internal drill was 15.
National Health Statistics Reports n Number 37 n March 24, 2011	 Page 5

Severe epidemics Mass vaccinations1 

Percent 

SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008. 

Scenario type 

1Significantly different from severe epidemic drill scenarios (both p < 0.05). 

95% confidence interval

 Community mass 

0 

10 

20 

30 

40 

50 

60 

70

 medication1 

22.5 

58.5 

32.5 

Figure 3. Percentage of hospitals participating in selected mass casualty drill scenario

types: United States, 2008

+ The median length of each hospital’s

longest internal drill was 4.0 hours.

+ The median number of table-top

exercises conducted in the last year

by a hospital was one.

External mass casualty

drills, simulations, or

exercises

+ In the last year, 28.4 percent of

hospitals conducted more than one

external drill (i.e., in collaboration

with other organizations);

53.6 percent conducted only one

external drill; 11.5 percent conducted

no external drills; and the number of

external drills was unknown for

6.5 percent of hospitals (Tables 4 and

5).

+ For those hospitals in which the

number of drills was known, the

median number of full-scale

simulations conducted in

collaboration with other organizations

(law enforcement, health department,

emergency management, fire

department, EMS, hazardous

materials teams, or decontamination

teams) was one.

+ The median number of adult victims

utilized in each hospital’s largest

external drill was 16.

+ The median length of each hospital’s

longest external drill was 4.0 hours.

+ The median number of table-top

exercises hospitals conducted in

collaboration with other organizations

was 0.5.

Types of scenarios in mass

casualty drills

+	 About 88.2 percent of hospitals

addressed general disaster and

emergency response in their drills,

significantly more than any other type

of scenario studied (Table 6).

+	 About the same percentages of

hospitals addressed decontamination

procedures (69.6 percent), severe

epidemics or pandemics

(58.5 percent), and chemical accidents

or attacks (55.6 percent) in their

drills.

+	 Compared with hospitals staging

decontamination scenarios,

significantly fewer hospitals

(42.5 percent) focused on acute

decontamination of aerosol exposures

from biological accidents or attacks.

+	 Compared with hospitals staging

severe epidemic scenarios, about the

same percentage (39.1 percent)

focused on delayed disease outbreak

management for biological accidents

or attacks. However, significantly

fewer hospitals addressed mass

vaccinations (32.5 percent), mass

medication distribution to hospital

personnel (30.6 percent), or mass

medication distribution to the

community (22.5 percent) (Figure 3).

+	 For mass medication distribution,

statistically similar percentages of

hospitals focused on hospital

personnel and the community.

+	 In their drills on biological accidents

or attacks, statistically similar

percentages of hospitals focused on

acute decontamination of aerosol

exposures and delayed disease

outbreak management.

+	 About 32.4 percent of hospitals

addressed explosive or incendiary

accidents or attacks in their drills,

significantly fewer than scenarios for

general disasters, decontamination,

epidemics, or chemical attacks, but

statistically similar to scenarios for

acute decontamination of biological

aerosol exposures and delayed disease

outbreak management for biological

attacks.

+	 About 18.7 percent of hospitals

addressed nuclear or radiological

accidents or attacks in their drills,

significantly fewer than scenarios for

general disasters, decontamination,

epidemics, chemical attacks, or acute

decontamination of biological aerosol

exposures, but statistically similar to

scenarios for delayed disease

outbreak management for biological

attacks and explosions.

+	 Statistically similar percentages of

hospitals addressed children

(44.6 percent) and the frail elderly

(36.2 percent) in their drills. But only

17.1 percent addressed mentally

challenged individuals in their drills,

significantly less than children or the

frail elderly.

Collaboration with outside

organizations on mass

casualty drills

+	 Statistically similar percentages of

hospitals performed drills,

simulations, or exercises with state or

local offices of emergency

management (85.8 percent), state or

local law enforcement (81.5 percent),

state or local public health

departments (81.3 percent), fire

departments (79.7 percent), and fire

department-based EMS (72.1 percent)

(Table 7).
Page 6 National Health Statistics Reports n Number 37 n March 24, 2011

+ About 69.7 percent of hospitals

performed drills with EMS not based

in a fire department, significantly

fewer than with offices of emergency

management, but statistically similar

to fire department-based EMS, law

enforcement, public health

departments, and fire departments.

+ Statistically similar percentages of

hospitals performed drills with

decontamination teams (58.4 percent)

and hazardous materials teams

(50.9 percent).

+ Statistically similar percentages of

hospitals performed drills with school

systems (30.6 percent), industrial or

commercial organizations

(25.8 percent), or long-term care

facilities (20.4 percent).

Mass casualty resources

+ For personal protection, the median

number of N95 masks per hospital

was 432, and the median number of

personal protective suits with

powered air-purifying respirators per

hospital was 10 (Table 8).

+ The median numbers of patients that

could be handled by hospital

decontamination showers per hour

was seven for ambulatory patients,

three for small children or infants,

and three for stretcher patients.

+ The median numbers of beds per

hospital was 70 for regular inpatient

staffed beds, 8 for critical care beds,

11 for ED treatment spaces, and 4 for

negative pressure isolation rooms.

+ The median number of mechanical

ventilators per hospital was six.

Ambulance diversion

When EDs are at capacity,

ambulance diversion is implemented.

Thus, the number of annual hours that

an ED is on ambulance diversion, or

that a hospital is on diversion for trauma

or critical care cases, reflects the

hospital’s capacity to accept new

patients, not only during routine

operations, but also during a mass

casualty incident (Table 9).

+ In 2007, the majority of hospitals

(58.7 percent) did not report being on

ED ambulance diversion. About

16.3 percent of hospitals were on

ambulance diversion for 220 hours or

less (equivalent to about 9.2 days),

which represented the mean for the

91.2 percent of hospitals for which

data were available. About

16.2 percent of hospitals were on

ambulance diversion for more than

220 hours. Ambulance diversion

information was unknown for

8.7 percent of hospitals.

+ In 2007, the majority of hospitals

(72.5 percent) did not report being on

trauma diversion. About 7.1 percent

of hospitals were on trauma diversion

for 32 hours or less (equivalent to

about 1.3 days), which represented

the mean for the 85.2 percent of

hospitals for which data were

available. The estimate was unreliable

for hospitals on trauma diversion for

more than 32 hours. Trauma diversion

information was unknown for

14.8 percent of hospitals.

+ In 2007, the majority of hospitals

(66.4 percent) did not report being on

critical care diversion. About

10.6 percent of hospitals were on

critical care diversion for 72 hours or

less (equivalent to three days), which

represented the mean for the

84.5 percent of hospitals for which

data were available. About 7.5 percent

of hospitals were on critical care

diversion for more than 72 hours.

Critical care diversion information

was unknown for 15.5 percent of

hospitals.

Hospital preparedness

funding

Between 2002 and 2007, about

one-quarter of hospitals (24.3 percent)

received more than $150,000 in federal

preparedness funding, 19.2 percent

received more than $75,000 but less

than $150,000, and 24.2 percent

received more than zero but less than

$75,000. About 5.2 percent received no

funding. The amount of funding was

unknown for 27.2 percent of hospitals

(Table 10).

Discussion

This emergency response

preparedness supplement contains

valuable information for federal, state,

and local planners who are responsible

for hospitals’ response to infectious

disease epidemics and other mass

casualty incidents. In this report,

baselines have been established for new

data elements. Future research will track

trends between 2003–2004 and 2008 for

data elements that are unchanged, and

identify hospital characteristics that are

associated with emergency preparedness.

There are several key issues that are

highlighted by this survey.

While nearly all hospitals have

emergency response plans for chemical

releases, natural disasters, epidemics or

pandemics, and biological accidents or

attacks, preparedness for explosive or

incendiary incidents is significantly less

frequent than preparedness for other

types of mass casualty incidents. A

similar trend was found with respect to

including explosion scenarios in mass

casualty drills. Explosive terrorism is

infrequent in the United States, with no

incidents having occurred since the 2001

airline attacks at the World Trade

Center, Pentagon, and over Pennsylvania

(9). However, incendiary incidents

(fires) are more common. The U.S. Fire

Administration reported that there were

about 15,500 fires in high-rise structures

between 1996 and 1998. While hospital

preparedness for fires most often

involves receiving casualties from

incidents occurring elsewhere, it is

noteworthy that about 6 percent of these

high-rise structure fires occurred in

hospitals (10).

ED crowding continues to be a

major policy issue. The Institute of

Medicine (IOM) has expressed concern

that many hospitals now operating at or

near full capacity lack the ability to

handle sudden increases in volume

associated with mass casualties (11).

The American College of Emergency

Physicians (ACEP) recommends that

hospitals develop influenza preparedness

plans to assure adequate inpatient surge

capacity by such means as opening

unused areas, doubling up inpatient

rooms, canceling elective admissions

and procedures, and using alternate

areas for extra critical care space (12).

We found that while most hospitals had

plans for cancellation of elective
National Health Statistics Reports n Number 37 n March 24, 2011	 Page 7

procedures and admissions, only about

two-thirds had plans for establishment

of alternate care areas with beds,

staffing, and equipment in nonclinical

space. Only about one-half had plans for

establishing alternate care areas in

inpatient unit hallways or

decommissioned ward space, or for

conversion of inpatient units to augment

intensive care capacity. One practice that

may be useful in decompressing EDs is

establishing alternate care areas in

inpatient hallways until regular beds

become available. Because of concerns

about the safety to patients of this

approach, one academic ED studied

adverse events resulting from their

institutional protocol for admitting

ED-boarded patients to inpatient hallway

beds during overcrowding situations.

In-hospital mortality and ICU transfers

were both significantly lower for

patients admitted to hallway beds than

for those admitted to standard inpatient

beds. The authors concluded that

hallway boarding was not harmful to

patients (13).

When resources for patient care

become scarce in disaster situations,

IOM recommends the development of

consistent state crisis standards of care

(14). One example of such a resource is

mechanical ventilators for patients in

respiratory failure due to infectious

agents that have compromised lung

function. We found that only about

one-half of hospitals had advance plans

for adjusted standards of care for

allocation of mechanical ventilators

during mass casualty incidents when

normal capacities might be

overwhelmed. But models do exist for

developing such standards. In one

tertiary medical center, a triage system

was developed and tested for instituting

or continuing mechanical ventilation

based on objective clinical factors

related to survival potential and

available resources. The system, which

involves a change in the standard of

care, would be implemented through the

health department and supported by a

declaration from the state governor with

professional liability protections in place

(15).

ACEP recommends that hospitals

create and execute a training program

based upon their emergency operations

plans, develop pandemic influenza

exercise programs, and execute an

exercise to test the validity of the

training and plans (12). As evidenced by

the 2009 H1N1 influenza epidemic,

mass vaccination and medication

distribution are frequently key

components of epidemic response. We

found that although more than one-half

of hospitals had staged epidemic drills,

only about one-third had included mass

vaccination or community medication

distribution specifically. In a survey of

health care epidemiologists following

the experience of the 2009 H1N1

influenza epidemic, only 60 percent felt

that their hospitals were well prepared

for a pandemic, and 31 percent reported

shortages of antiviral medications. The

authors identified pandemic influenza

plan revisions and consideration of

mandatory influenza vaccinations for

health care workers as important

priorities (16).

The Emergency System for

Advance Registration of Volunteer

Health Professionals Grant Program of

the U.S. Office of the Assistant

Secretary for Preparedness and

Response helps health professionals

volunteer in public health emergencies

by providing verifiable information

about their identity, license, credentials,

and clinical privileges to participating

medical facilities (17). Despite the

existence of this federal initiative, we

found that about one-half of hospitals

had plans for advance registration of

outside health care professionals.

Planning for special populations,

including children, appears to be less

common than planning for adult

patients. For example, ACEP

recommends that written transfer

protocols and interfacility agreements

should be in place when patient transfer

is part of a regional plan to provide

optimal specialized care (18). While

most hospitals have MOUs with other

hospitals to accept adult patients in

transfer during an epidemic, fewer

hospitals have MOUs for pediatric and

burn patients. Similarly, less than

one-half of hospitals had various

programs in place to accommodate the

needs of children and persons with

disabilities during a public health

emergency.

References

1.Niska RW, Burt CW. Bioterrorism

and mass casualty preparedness in

hospitals: United States, 2003.

Advance data from vital and health

statistics; no 364. Hyattsville, MD:

National Center for Health Statistics.

2005. Available from: http://

www.cdc.gov/nchs/data/ad/ad364.pdf.

2.Niska RW, Burt CW. Training for

terrorism-related conditions in

hospitals: United States, 2003–04.

Advance data from vital and health

statistics; no 380. Hyattsville, MD:

National Center for Health Statistics.

2006. Available from: http://

www.cdc.gov/nchs/data/ad/ad380.pdf.

3.Niska RW, Burt CW. Emergency

response planning in hospitals,

United States: 2003–2004. Advance

data from vital and health statistics;

no 391. Hyattsville, MD: National

Center for Health Statistics. 2007.

Available from: http://www.cdc.gov/

nchs/data/ad/ad391.pdf.

4.Niska RW. Hospital collaboration

with public safety organizations on

bioterrorism response. Prehosp

Emerg Care 12(1):12–7. 2008.

5.World Health Organization Global

Influenza Program Surveillance

Network. Evolution of H5N1 avian

influenza viruses in Asia. Emerg

Infect Dis 11(10):1515–21. 2005.

6.World Health Organization.

Cumulative number of confirmed

human cases of avian influenza

A/(H5N1) reported to WHO. 2009.

Available from: http://www.who.int/

csr/disease/avian_influenza/country/

cases_table_2009_01_07/en/

index.html.

7.World Health Organization. Nations

with confirmed cases H5N1 avian

influenza (map). Available from:

http://www.pandemicflu.gov/images/

pop_image.gif.

8.SUDAAN (Release 9.0.1) [Computer

Software]. Research Triangle Park,

NC: Research Triangle Institute.

2005.

9.Information Please Database.

Terrorist attacks in the U.S. or

against Americans. Available from

http://www.infoplease.com/ipa/

A0001454.html.

10. U.S. Fire Administration. Highrise

fires. Topical Fire Research Series
Page 8 National Health Statistics Reports n Number 37 n March 24, 2011

2(18):1–7. 2002. Available from:

http://www.usfa.dhs.gov/downloads/

pdf/tfrs/v2i18–508.pdf.

11. Institute of Medicine of the National

Academies. Improving the efficiency

of hospital-based emergency care.

Chapter 4 in: Future of emergency

care: Hospital-based emergency care

at the breaking point. Washington,

DC: National Academies Press

129–64. 2007.

12. American College of Emergency

Physicians. National strategic plan

for emergency department

management of outbreaks of novel

H1N1 influenza. Available from:

http://www.acep.org/assets/0/16/898/

904/908/99911/b51b7c76-e1e3–4123­

91a3–5416055544b5.pdf.

13. Viccellio A, Santora C, Singer AJ,

Thode HC Jr, Henry MC. The

association between transfer of

emergency department boarders to

inpatient hallways and mortality: A

4-year experience. Ann Emerg Med

54(4):511–3. 2009.

14. Institute of Medicine of the National

Academies. Guidance for establishing

crisis standards of care for use in

disaster situations: A letter report.

Report Brief 1–4. 2009. Available

from: http://www.iom.edu/~/media/

Files/Report%20Files/2009/Disaster

CareStandards/Standards%20of%

20Care%20report%20brief%

20FINAL.pdf.

15. Hick JL, O’Laughlin DT. Concept of

operations for triage of mechanical

ventilation in an epidemic. Acad

Emerg Med 13(2):223–9. 2006.

16. Lautenbach E, Saint S, Henderson

DK, Harris AD. Initial response of

health care institutions to emergence

of H1N1 influenza: experiences,

obstacles, and perceived future needs.

Clin Infect Dis 50(4):528–30. 2010.

17. Assistant Secretary for Preparedness

and Response. Emergency system for

advance registration of volunteer

health professionals grant program.

Available from: http://www07.

grants.gov/search/search.do?&

mode=VIEW&oppId=54485.

18. American College of Emergency

Physicians. Appropriate interhospital

patient transfer. Ann Emerg Med

54(1):141. 2009.
National Health Statistics Reports n Number 37 n March 24, 2011 Page 9

Table 1. Hospitals with emergency response plans for selected types of incidents: United States, 2008

Number of

Type of incident hospitals Percent SE 95% confidence interval

Chemical accidents or attacks ........................... 5,162 99.0 0.3 98.1 99.5 

Natural disasters ................................... 5,095 97.8 0.8 95.4 98.9 

Epidemics or pandemics .............................. 4,904 94.1 1.9 88.9 96.9 

Biological accidents or attacks ........................... 4,859 93.2 2.2 87.4 96.5 

Nuclear or radiological accidents or attacks................... 4,235 81.3 4.5 70.7 88.6 

Explosive or incendiary accidents or attacks .................. 4,147 79.6 4.1 70.3 86.5 

All types of incidents ................................. 3,540 67.9 4.7 58.0 76.4 

NOTES: Unweighted sample size is 294, representing a weighted national estimate of 5,212 hospitals. SE is standard error of percent.

Table 2. Hospitals engaged in cooperative planning in developing or updating a response plan for public health emergencies, by type of

entity engaged: United States, 2008

Number of

Type of outside entity engaged hospitals Percent SE 95% confidence interval

State or local office of emergency management ................ 4,884 93.7 1.9 88.7 96.6 

Other hospitals .................................... 4,832 92.7 2.7 85.2 96.6 

Emergency medical services ............................ 4,640 89.0 3.3 80.7 94.0 

State or local public health department ..................... 4,622 88.7 3.1 80.9 93.6 

State or local law enforcement........................... 4,492 86.2 2.9 79.4 91.0 

Fire department .................................... 4,483 86.0 3.4 77.9 91.5 

Hazardous materials teams............................. 3,351 64.3 5.6 52.6 74.5 

Federal Bureau of Investigation .......................... 992 19.0 3.2 13.6 26.0 

All eight entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 973 18.7 3.2 13.2 25.7 

NOTES: Unweighted sample size is 294, representing a weighted national estimate of 5,212 hospitals. SE is standard error of percent.
Page 10 National Health Statistics Reports

n Number 37n March 24, 2011

s in a written plan for use during an overcrowding incident or public health emergency, by type of plan component: United States,

In emergency response plan Used in 2007 incident

an component Number Percent SE 95% confidence interval Number Percent SE 95% confidence interval

with outside entities

ED . . . . . ........................

rom ED ...........................

ansfer ............................

................................

ns ..............................

................................

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

................................

................................

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

................................

................................

nd equipment .......................

4,5782,9272,9652,2284,445

4,2033,6513,3764,6734,2733,5312,706

4,381

87.856.256.942.885.3

80.670.164.889.782.067.851.9

84.1

3.25.65.74.23.4

4.54.74.82.63.03.34.6

3.8

80.045.145.434.877.1

70.360.154.983.375.260.942.8

75.2

92.966.767.751.190.9

88.078.473.693.887.273.960.9

90.2

446416

**

1523

1180

880736

15841237

987788

850

8.68.0

**

29.2

22.616.914.1

30.423.7

18.915.1

16.3

1.81.9

**

4.3

3.43.03.0

3.93.5

3.43.2

3.5

5.65.0

**

21.4

16.6

11.7

9.2

23.217.5

13.2

9.9

10.5

12.812.6

**

38.4

30.123.721.2

38.731.4

26.522.5

24.4

n-site surge capacity

ssions ............................

................................

e ...............................

................................

................................

................................

................................

4,5004,7192,642

2,7282,5893,5793,842

86.390.550.7

52.349.768.773.7

3.42.54.6

4.34.43.83.8

78.284.541.7

43.941.160.765.6

91.894.459.6

60.758.375.780.5

671738

*

****

12.914.2

*

****

1.82.4

*

****

9.8

10.0

*

****

16.819.7

*

****

or limited resources

................................

ntilation ...........................

sources ...........................

of care............................

1,712

2,2533,7713,335

32.9

43.272.464.0

5.2

4.23.94.8

23.6

35.264.254.0

43.7

51.679.372.9

*

***

*

***

*

***

*

***

*

***

health care work force

................................

roviders ..........................

ssionals ..........................

mpact ............................

pital .............................

4,629

3,6212,9143,4893,291

88.8

69.555.966.963.1

2.8

4.75.04.94.4

82.0

59.546.056.854.1

93.3

77.965.475.871.4

775

 

14.9

** **

2.4

 

10.8

** **

20.2

 

alty management

atients............................

ients .............................

................................

...............................

4,3714,0124,9303,264

83.977.094.662.6

3.03.91.83.9

76.968.489.854.7

89.083.897.269.9

** **

 

** **

 

** **
National Health Statistics Reports

n Number 37n March 24, 2011 Page 11

s in a written plan for use during an overcrowding incident or public health emergency, by type of plan component: United States,

In emergency response plan Used in 2007 incident

an component Number Percent SE 95% confidence interval Number Percent SE 95% confidence interval

ediatric

city ............................. 1,687 32.4 3.9 25.2 40.5 * * * * *

dren rapidly......................... 1,621 31.1 3.7 24.4 38.8 * * * * *

................................ 2,222 42.6 4.1 34.8 50.9 * * * * *

................................ 1,774 34.0 3.8 27.1 41.8 * * * * *

ren ............................. 1,531 29.4 4.1 22.0 38.0 * * * * *

populations

................................ 3,036 58.3 5.0 48.2 67.6 * * * * *

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,476 47.5 4.9 38.1 57.1 * * * * *

tients ............................ 3,820 73.3 4.2 64.3 80.7 804 15.4 4.1 8.9 25.3

................................ 2,481 47.6 4.4 39.2 56.2 * * * * *

................................ 1,757 33.7 3.9 26.5 41.8 * * * * *

................................ 2,042 39.2 3.9 31.7 47.2 * * * * *

eeds ............................. 2,433 46.7 4.0 39.0 54.5 2187 42.0 3.9 34.6 49.8

. ............................... 2,034 39.0 3.9 31.6 47.0 * * * * *

munications

ent ............................. 4,866 93.4 2.3 87.1 96.7 1800 34.5 4.2 26.9 43.1

za vaccination ....................... 4,140 79.4 3.0 73.0 84.7 1536 29.5 4.0 22.2 38.0

than 30 unweighted cases).

g a weighted national estimate of 5,212 hospitals. SE is standard error of percent. MOU is memoranda of understanding. ED is emergency department.
Page 12 National Health Statistics Reports n Number 37 n March 24, 2011

Table 4. Internal and external mass casualty drills (number and percent distribution): United States, 2008

Number of internal drills

Number of

Internal drills hospitals Percent SE 95% confidence interval

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5,212 100.0 . . . . . . . . . 

No drills......................................... 578 11.1 2.4 7.2 16.8 

One drill ........................................ 1,661 31.9 4.3 24.0 40.9 

More than one drill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,638 50.6 5.5 39.9 61.3 

Unknown ........................................ 335 *6.4 2.8 2.6 14.8 

Drills in collaboration with other organizations

Number of

Number of external drills hospitals Percent SE 95% confidence interval

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5,212 100.0 . . . . . . . . . 

No drills......................................... 599 11.5 2.5 7.4 17.5 

One drill ........................................ 2,794 53.6 3.9 45.9 61.2 

More than one drill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,482 28.4 3.9 21.4 36.7 

Unknown ........................................ 337 *6.5 2.1 3.3 12.2 

. . . Category not applicable.

* Figure does not meet standards of precision (relative standard error greater than 30%). 

NOTES: Total unweighted sample size is 294, representing a weighted national estimate of 5,212 hospitals. SE is standard error of percent. 

Table 5. Internal and external mass casualty drills (median number of drills, number of victims, and length of longest drill): United

States, 2008

Internal drills

Number of

hospitals Median SE Interquartile range

Full-scale simulations ................................ 4,877 1.1 0.1528 0.4 1.9 

Number of victims in largest drill

Adult . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,058 14.9 2.5 4.8 26.1

Pediatric ..................................... 3,752 *1.4 0.6 ** 4.2

Length of longest drill (hours) .......................... 4,271 4.0 0.5 3.4 20.3 

Table-top exercises.................................. 4,373 0.7 0.1 0.1 1.5 

External drills (in collaboration with other organizations)

Number of

hospitals Median SE Interquartile range

Full-scale simulations ................................ 4,875 0.7 0.1 0.2 1.3 

Number of victims in largest drill

Adult . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,006 15.6 2.2 6.0 24.9

Pediatric ..................................... 3,681 1.2   4.6

Length of longest drill (hours) .......................... 4,189 4.0 0.5 3.9 19.5 

Table-top exercises.................................. 4,436 0.5 0.1 **  1.3 

* Figure does not meet standards of precision (relative standard error greater than 30%).

** Not possible to extrapolate data to compute value.

NOTES: Total unweighted sample size is 294, representing a weighted national estimate of 5,212 hospitals. Number of hospitals excludes those for which the number of drills is unknown. SE is

standard error of median.
National Health Statistics Reports n Number 37 n March 24, 2011 Page 13

Table 6. Type of drill scenario among hospitals participating in mass casualty drills: United States, 2008

Number of

Type of scenario hospitals Percent SE 95% confidence interval

General disaster and emergency response ........................ 4,599 88.2 3.2 80.2 93.3 

Decontamination procedures................................. 3,627 69.6 4.2 60.8 77.1 

Severe epidemic or pandemic ................................ 3,051 58.5 4.3 49.9 66.7 

Chemical accidents or attacks ................................ 2,898 55.6 4.3 47.0 63.9 

Biologic accidents or attacks................................. 

Decontamination of aerosol exposure .......................... 2,213 42.5 4.0 34.9 50.4 

Delayed disease outbreak management ........................ 2,038 39.1 5.4 29.0 50.2 

Mass vaccinations ....................................... 1,692 32.5 4.6 24.1 42.1 

Explosive or incendiary accidents or attacks ....................... 1,689 32.4 3.6 25.8 39.8 

Mass medication distribution to hospital personnel ................... 1,597 30.6 4.9 22.0 41.0 

Mass medication distribution to community . . . . . . . . . . . . . . . . . . . . . . . . 1,174 22.5 4.3 15.2 32.0 

Nuclear or radiological accidents or attacks ....................... 972 18.7 2.8 13.8 24.8 

Special populations 

Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,324 44.6 3.9 37.0 52.4 

Frail elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,886 36.2 4.0 28.6 44.5 

Mentally challenged..................................... 892 17.1 3.6 11.2 25.3 

NOTES: Unweighted sample size is 294, representing a weighted national estimate of 5,212 hospitals. SE is standard error of percent.

Table 7. Type of organization with which hospitals collaborate in external mass casualty drills: United States, 2008

Hospital collaborating with organization

Number of 

Type of collaborating organization hospitals Percent SE 95% confidence interval 

State or local office of emergency management ..................... 4,471 85.8 2.5 80.0 90.1 

State or local law enforcement ............................... 4,248 81.5 2.7 75.5 86.3 

State or local public health department .......................... 4,235 81.3 3.3 73.8 87.0 

Fire department......................................... 4,155 79.7 3.0 73.1 85.0 

EMS: fire department based ................................. 3,760 72.1 3.7 64.3 78.8 

EMS: not based in fire department ............................. 3,633 69.7 4.0 61.2 77.0 

Decontamination teams .................................... 3,042 58.4 4.0 50.3 66.1 

Hazardous materials teams ................................. 2,652 50.9 4.8 41.6 60.1 

School systems......................................... 1,595 30.6 4.2 23.0 39.5 

Industrial or commercial organizations ........................... 1,347 25.8 4.1 18.7 34.6 

Long-term care facilities.................................... 1,061 20.4 3.4 14.5 27.8 

NOTES: Unweighted sample size is 294, representing a weighted national estimate of 5,212 hospitals. SE is standard error of percent. EMS is emergency medical services.

Table 8. Selected emergency response resources and capabilities in hospitals: United States, 2008

Number of

Type of equipment hospitals Median SE Interquartile range

Mechanical ventilators..................................... 4,814 5.7 0.9 2.0 19.4 

N95 masks ........................................... 3,912 432.1 78.0 128.2 1,494.7 

Personal protective suits with PAPR ............................ 4,705 9.7 1.0 5.4 19.2 

Emergency department treatment spaces......................... 4,953 10.5 1.1 5.1 21.6 

Critical care beds........................................ 4,807 8.5 1.0 3.7 26.3 

Negative pressure isolation rooms ............................. 5,020 4.1 0.4 1.0 10.0 

Regular inpatient staffed beds ................................ 4,817 70.4 15.5 24.6 158.6 

Decontamination showers 

Ambulatory patients per hour ............................... 4,863 7.0 1.1 1.4 19.8 

Stretcher patients per hour ................................ 4,776 3.0 0.4 0.8 7.9 

Small children or infants per hour ............................ 4,429 3.4 0.9 0.6 13.4 

NOTES: Unweighted sample size is 294, representing a weighted national estimate of 5,212 hospitals. Number of hospitals excludes those for which the number of selected resources or

capabilities is unknown. SE is standard error of median. PAPR is powered air purifying respirator.
Page 14 National Health Statistics Reports n Number 37 n March 24, 2011

Table 9. Annual hours spent on diversion status, by type of diversion: United States, 2008

Number of

Diversion type hospitals Percent SE 95% confidence interval

Total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5,212 100.0 . . . . . . . . .

Ambulances to emergency department

None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,061 58.7 3.8 51.0 66.0

1 to 220 hours1 ....................................... 850 16.3 2.8 11.5 22.6

More than 220 hours .................................... 846 16.2 2.8 11.4 22.5

Unknown ........................................... 455 8.7 1.8 5.8 13.0

Trauma

None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,777 72.5 3.1 65.9 78.2

1 to 32 hours2 ........................................ 370 7.1 1.9 4.2 11.7

More than 32 hours ..................................... 295 *5.7 1.8 3.0 10.6

Unknown ........................................... 770 14.8 2.0 11.2 19.3

Critical care cases

None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,461 66.4 3.2 59.9 72.3

1 to 72 hours3 ........................................ 551 10.6 2.3 6.9 16.0

More than 72 hours ..................................... 393 7.5 1.7 4.8 11.6

Unknown ........................................... 807 15.5 2.3 11.5 20.6

. . . Category not applicable.

* Figure does not meet standards of precision (relative standard error greater than 30%).

1

The mean was 220.4 hours. The median and mode were zero.

2

The mean was 31.6 hours. The median and mode were zero.

3

The mean was 72.1 hours. The median and mode were zero.

NOTES: Unweighted sample size is 294, representing a weighted national estimate of 5,212 hospitals. SE is standard error.

Table 10. Total funding received per hospital from federal hospital preparedness programs: United States, 2002–2007

Funding

Number of

hospitals Percent SE 95% confidence interval

Total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5,212 100.0 . . . . . . . . .

None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$1-$75,000 ...........................................

$75,001-$150,000 .......................................

More than $150,000 ......................................

Unknown.............................................

270

1,259

1,002

1,265

1,416

*5.2

24.2

19.2

24.3

27.2

1.7

5.4

4.8

2.7

4.4

2.7

15.1

11.5

19.4

19.4

9.9

36.3

30.5

29.9

36.6

. . . Category not applicable. 

* Figure does not meet standards of precision (relative standard error greater than 30%). 

NOTE: Unweighted sample size is 294, representing a weighted national estimate of 5,212 hospitals. SE is standard error of percent. 
Page 16 National Health Statistics Reports n Number 37 n March 24, 2011

Acknowledgments

This report was prepared in the Division of Health Care Statistics. Victor Shigaev, Roberto Valverde, and Elizabeth Rechtsteiner in the

Technical Services Branch performed the sample weighting and edited the data set. Nancy Sonnenfeld contributed to the discussion section.

The report was edited and produced by CDC/OSELS/NCHS/OD/Office of Information Services, Information Design and Publishing Staff: Betsy

M. Finley edited the report; typesetting was done by Annette F. Holman; and graphics were produced by John Jeter.

Suggested citation

Niska RW, Shimizu IM. Hospital preparedness

for emergency response: United States, 2008.

National health statistics reports; no 37.

Hyattsville, MD: National Center for Health

Statistics. 2011.

Copyright information

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copied without permission; citation as to

source, however, is appreciated.

National Center for Health Statistics

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Jennifer H. Madans, Ph.D., Associate Director 

for Science 

Division of Health Care Statistics

Jane E. Sisk, Ph.D, Director

U.S. DEPARTMENT OF

HEALTH & HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

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