Emergency Preparedness: States Are Planning for Medical Surge, but Could Benefit from Shared Guidance for Allocating Scarce Medical Resources
Published: 2008-06-13T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Potential terrorist attacks and the possibility of naturally occurring disease outbreaks have raised concerns about the "surge capacity" of the nation's health care systems to respond to mass casualty events. GAO identified four key components of preparing for medical surge: (1) increasing hospital capacity, (2) identifying alternate care sites, (3) registering medical volunteers, and (4) planning for altering established standards of care. The Department of Health and Human Services (HHS) is the primary agency for hospital preparedness, including medical surge. GAO was asked to examine (1) what assistance the federal government has provided to help states prepare for medical surge, (2) what states have done to prepare for medical surge, and (3) concerns states have identified related to medical surge. GAO reviewed documents from the 50 states and federal agencies. GAO also interviewed officials from a judgmental sample of 20 states and from federal agencies, as well as emergency preparedness experts.
section_title: What GAO Found
paragraphs: Following a mass casualty event that could involve thousands, or even tens of thousands, of injured or ill victims, health care systems would need the ability to "surge," that is, to adequately care for a large number of patients or patients with unusual medical needs. The federal government has provided funding, guidance, and other assistance to help states prepare for medical surge in a mass casualty event. From fiscal years 2002 to 2007, the federal government awarded the states about $2.2 billion through the Office of the Assistant Secretary for Preparedness and Response's Hospital Preparedness Program to support activities to meet their preparedness priorities and goals, including medical surge. Further, the federal government provided guidance for states to use when preparing for medical surge, including Reopening Shuttered Hospitals to Expand Surge Capacity, which contains a checklist that states can use to identify entities that could provide more resources during a medical surge. Based on a review of state emergency preparedness documents and interviews with 20 state emergency preparedness officials, GAO found that many states had made efforts related to three of the key components of medical surge, but fewer have implemented the fourth. More than half of the 50 states had met or were close to meeting the criteria for the five medical-surge-related sentinel indicators for hospital capacity reported in the Hospital Preparedness Program's 2006 midyear progress reports. For example, 37 states reported that they could add 500 beds per million population within 24 hours of a mass casualty event. In a 20-state review, GAO found that all 20 were developing bed reporting systems and most were coordinating with military and veterans hospitals to expand hospital capacity, 18 were selecting various facilities for alternate care sites, 15 had begun electronic registering of medical volunteers, and fewer of the states--7 of the 20--were planning for altered standards of medical care to be used in response to a mass casualty event. State officials in GAO's 20-state review reported that they faced challenges relating to all four key components in preparing for medical surge. For example, some states reported concerns related to maintaining adequate staffing levels to increase hospital capacity, and some reported concerns about reimbursement for medical services provided at alternate care sites. According to some state officials, volunteers were concerned that if state registries became part of a national database they might be required to provide services outside their own state. Some states reported that they had not begun work on or completed altered standards of care guidelines due to the difficulty of addressing the medical, ethical, and legal issues involved in making life-or-death decisions about which patients would get access to scarce resources. While most of the states that had adopted or were drafting altered standards of care guidelines reported using federal guidance as they developed these guidelines, some states also reported that they needed additional assistance.

section_title: Letter
paragraphs: The September 11, 2001, terrorist attacks on the World Trade Center and  the Pentagon, the anthrax incidents during the fall of 2001, and the  possibility of a naturally occurring disease outbreak or some other large- scale public health emergency have raised public awareness and concern  about the ability of the nation’s health care systems to respond to  bioterrorism and other mass casualty events. In a mass casualty event the  ability of local or regional health care systems to deliver services  consistent with established standards of care could be compromised, at  least in the short term, because the volume of patients would far exceed  the available hospital beds, medical personnel, pharmaceuticals,  equipment, and supplies.
Following a mass casualty event, health care systems would need the  ability to “surge,” that is, to adequately care for a large number of patients  or patients with unusual or highly specialized medical needs. Providing  such care would require the allocation of scarce resources and could  occur outside of hospitals and other normal health care delivery sites.  Through literature reviews and interviews with experts and professional  associations, we identified four key components related to preparing for  medical surge in a mass casualty event: (1) increasing hospital capacity,  including beds, workforce, equipment, and supplies; (2) identifying and  operating alternate care sites when hospital capacity is overwhelmed;   (3) registering and credentialing volunteer medical professionals; and   (4) planning for appropriate altered standards of care in order to save the  most lives in a mass casualty event.
Federal and state entities both play roles in preparing for emergency  preparedness. The Department of Homeland Security (DHS) has the  overall federal responsibility under the Homeland Security Act of 2002 for  managing national emergency preparedness. In December 2006, the  Congress passed the Pandemic and All-Hazards Preparedness Act  (PAHPA). PAHPA designated the Secretary of Health and Human Services  as the lead official for all federal public health and medical responses to  public health emergencies, including medical surge. Under the federal  plan for responding to emergencies, states have responsibility for  producing emergency preparedness plans in coordination with regional  and local entities, and both DHS and the Department of Health and Human  Services (HHS) are responsible for supporting their efforts. In addition,  the Department of Defense (DOD) and the Department of Veterans Affairs  (VA) are expected to assist state and local entities in emergencies. A DOD  directive authorizes local military hospitals to coordinate with state and  local entities to plan for emergency preparedness, and DOD hospitals are  authorized to accept civilian patients in a mass casualty event. VA  policies and procedures allow VA hospitals to participate in state and local  emergency planning, and by statute VA may provide medical care to  nonveterans in a mass casualty event.
As a result of the nation’s need to prepare for potential terrorist attacks,  naturally occurring disease outbreaks, or other natural disasters, members  of the Congress asked that we undertake a study regarding the nation’s  preparedness for a mass casualty event. In this report, we examine the  following questions: (1) What assistance has the federal government  provided to help states prepare their regional and local health care  systems for medical surge in a mass casualty event? (2) What have states  done to prepare for medical surge in a mass casualty event? (3) What  concerns have states identified as they prepare for medical surge in a mass  casualty event?
To determine what assistance the federal government provided to states to  help them prepare their regional and local health care systems for medical  surge in a mass casualty event, particularly related to four key components  of medical surge, we reviewed and analyzed national strategic planning  documents. We also analyzed reports related to medical surge capacity  issued by various entities, including the Agency for Healthcare Research  and Quality (AHRQ), Centers for Disease Control and Prevention (CDC),  Office of the Assistant Secretary for Preparedness and Response (ASPR),  and the Joint Commission. In addition, we obtained and reviewed  documents from ASPR to determine the amount of funds awarded to  states through its Hospital Preparedness Program’s cooperative  agreements. We also interviewed officials from ASPR, CDC, and DHS to  identify and document criteria and guidance given to states to plan for  medical surge. To determine what states have done to prepare for medical  surge in a mass casualty event, we obtained and analyzed the 2006 and  2007 ASPR Hospital Preparedness Program cooperative agreement  applications and 2006 midyear progress reports (the most current  available information at the time of our data collection) for the 50 states.
We also reviewed the 15 sentinel indicators from these reports. Although  ASPR’s 2006 guidance for these midyear progress reports did not provide  specific criteria with which to evaluate recipients’ performance on these  sentinel indicators, we identified criteria to analyze the data provided for 5  of the indicators related to one of four key components—hospital  capacity—from either ASPR’s previous program guidance or DHS  guidance. (See app. I for a list of the sentinel indicators.) In addition, we  obtained and reviewed 20 states’ emergency preparedness planning  documents relating to medical surge and interviewed officials from these  states responsible for planning for medical surge. We selected the 20 states  by identifying 2 states from each of the 10 HHS geographic regions—one  with the most ASPR Hospital Preparedness Program funding and one with  the least funding. These selection criteria allowed us to take into account  population (program funding was awarded using a formula including, in  part, population), geographic dispersion, and different geographic risk  factors, such as the potential for hurricanes, tornadoes, or earthquakes.  We obtained and reviewed DOD and VA policies and interviewed officials  regarding their participation with state and local entities in emergency  preparedness planning and response. To determine what concerns states  identified as they prepared for medical surge, we interviewed emergency  preparedness officials from the 20 states on their efforts related to four  key components. We also asked what further assistance states might need  from the federal government to help prepare their health care systems for  medical surge. The information from these interviews is intended to  provide a general description of what the 20 states have done to prepare  for medical surge and is not generalizable to all 50 states. (See app. II for a  more detailed scope and methodology.) We conducted our work from May  2007 through May 2008 in accordance with generally accepted government  auditing standards.
subsections: section_title: Background
paragraphs: Federal responsibilities for assisting states in preparing for emergencies  include developing national strategies, policies, and guidelines and  providing funding to assist states in developing their emergency  preparedness plans and programs. A critical element of emergency  preparedness is preparing health care systems for medical surge in a mass  casualty event, and consideration of hospital capacity, alternate care sites,  electronic medical volunteer registries, and altered standards of care is  key to this task.
subsections: section_title: Federal Responsibilities Relating to States’ Preparedness for Medical Surge
paragraphs: DHS is responsible for developing national strategies, policies, and  guidelines related to emergency preparedness. Additionally, DHS  administers the Homeland Security Grant Program, which currently  consists of four programs—the State Homeland Security Program, Urban  Areas Security Initiative, Metropolitan Medical Response System, and  Citizens Corps Program. While these programs generally award funds to  states and municipalities for the prevention and detection of terrorist acts,  some funds can be spent on medical response, including medical surge  activities.
HHS has the principal responsibility for helping states to prepare for  medical surge. In December 2006, PAHPA established ASPR within HHS in  order to enhance coordination of public health and medical surge. The act  reauthorized and gave ASPR authority over the Hospital Preparedness  Program, which provides funds annually to 62 entities—the 50 states, 4  municipalities, 5 U.S. territories, and 3 Freely Associated States of the  Pacific—through cooperative agreements in order to strengthen their  emergency readiness capabilities. Also, beginning in fiscal year 2009, HHS  will require that states provide a 5 percent match to the amount of the  federal cooperative agreement funding, through either state funds or in- kind contributions, such as office space or computer support for the  program. In 2010 and subsequent years, the matching requirement will  increase to 10 percent.
As part of the 2006 Hospital Preparedness Program, ASPR required all  cooperative agreement recipients to submit midyear progress reports that  include data on 15 sentinel indicators, 13 of which are related to medical  surge. For example, one of the sentinel indicators is the number of  hospitals that have the capacity to maintain at least one patient with a  suspected highly infectious disease in a negative pressure isolation room.  PAHPA also gave ASPR authority for the Emergency System for Advance  Registration of Volunteer Health Professionals (ESAR-VHP). ESAR-VHP  supports state-based electronic databases designed to register health care  personnel who volunteer to provide medical care in an emergency for the  purpose of verifying their credentials. In order to continue to receive  Hospital Preparedness Program funds, states must participate in ESAR- VHP by fiscal year 2009. Under PAHPA, HHS is required to link state  electronic medical volunteer registries into a national registry.
DOD and VA do not have a federal responsibility in assisting states in  planning and preparing for medical surge in a mass casualty event.  However, since their hospitals are accredited by the Joint Commission,  they are required to participate in at least one annual emergency  preparedness exercise with their local community. In addition, because  they are part of the local community, they would play a role in planning for  and responding to local mass casualty events.
section_title: Key Components of Medical Surge in a Mass Casualty Event
paragraphs: According to Homeland Security Presidential Directive 21 (HSPD-21)  Public Health and Medical Preparedness, issued in October 2007, mass  casualty health care is a critical element of public health and medical  preparedness. HSPD-21 is one of a series of executive orders released  since September 11, 2001, establishing a national strategy to help protect  the nation in the event of terrorist attacks or other catastrophic health  events. It states that mass casualty health care capability needs to be  different from “day-to-day” public health and medical operations, which  “cannot meet the needs created by a catastrophic health event.” It also  states that the nation must develop a disaster medical capability that,  among other things, is rapid, flexible, sustainable, integrated, and  coordinated, and delivers appropriate treatment in the most ethical  manner with available capabilities.
The four key components we identified follow:    Hospital capacity: Following a mass casualty event, hospitals may need the  ability to adequately care for a large number of additional patients.  Strategies to increase hospital capacity include deferring elective  procedures, applying more stringent triage for admitting patients,  discharging patients early with follow-up by home health care personnel,  and adding additional beds and equipment in areas of the hospital that are  not normally used for inpatient care, such as outpatient examining rooms.
Alternate care sites: A mass casualty event could overwhelm hospitals’  capacity and require the establishment of alternate sites to provide health  care services. Alternate care sites deliver medical care outside hospital  settings for patients who would normally be treated as inpatients, and  triage patients in order to sort those who need critical attention and  immediate transport to the hospital from those with less serious injuries.  In addition, alternate care sites manage unique considerations that might  arise in the context of mass casualty events, including the delivery of  chronic care; the distribution of vaccines; or the quarantine, grouping, or  sequestration of patients potentially infected with an easily transmissible  infectious disease. The development of alternate care sites involves  several issues, including the level and scope of medical care to be  delivered, the physical infrastructure required, staffing requirements for  the delivery of such care, the medical equipment and supplies needed, and  the management systems required to integrate such facilities with the  overall delivery of health care. Additionally, there are two types of  alternate care sites—fixed and mobile. Fixed facilities are nonmedical  buildings that, because of their size or proximity to a hospital, can be  adapted to provide medical care. Mobile medical facilities are either  specialized units with surgical and intensive care capabilities that are  based on tractor-trailer platforms or fully equipped hospitals stored in  container systems that can be set up quickly.
Electronic medical volunteer registries: In a time of emergency, it can be  difficult for state and hospital officials who are organizing a response to  use medical volunteers unless they have been preregistered to determine  who is qualified to provide medical assistance. For example, immediately  after the attacks on September 11, 2001, thousands of people  spontaneously arrived in New York City to volunteer their assistance— many of whom volunteered to provide medical assistance to the victims of  the attacks. However, authorities were unable to distinguish medically  qualified from unqualified volunteers. Generally, an electronic medical  volunteer registry would (1) preregister health care volunteers, (2) apply  emergency credentialing standards to these registered volunteers, and   (3) allow for the verification of the identity, credentials, and qualifications  of registered volunteers in an emergency.
Altered standards of care: In a mass casualty event, routine resource  shortages would be significantly magnified and hospitals would have  limited access to many needed resources, such as health care providers,  equipment and supplies, and pharmaceuticals. As a result, it could be  necessary to alter standards of medical care in a manner that is different  from normal day-to-day circumstances and appropriate to the situation.  For example, because of an influx of a large number of patients in a mass  casualty event, adequate staffing of health care providers would be  hindered by the current shortages of health care providers. Workforce  shortages could result in hospitals changing their established standards of  care, such as nurse-to-patient care ratios.
section_title: The Federal Government Has Provided States with Funding, Guidance, and Other Assistance to Prepare for Medical Surge
paragraphs: The federal government has provided funding, guidance, and other  assistance to help states prepare their regional and local health care  systems for medical surge in a mass casualty event. From fiscal years 2002  through 2007, the federal government awarded the states about $2.2 billion  through ASPR’s Hospital Preparedness Program to support activities to  meet their preparedness priorities and goals, including medical surge.  Further, the federal government developed, or contracted with experts to  develop, guidance that was provided for states to use when preparing for  medical surge. In addition, the federal government provided other  assistance, such as conferences for states.
subsections: section_title: Funding to Prepare for Medical Surge
paragraphs: From fiscal years 2002 through 2007, HHS awarded states about   $2.2 billion through ASPR’s Hospital Preparedness Program to support  activities to strengthen their hospital emergency preparedness capabilities,  including medical surge goals and priorities. (See app. III for Hospital  Preparedness Program cooperative agreement funding by state.) ASPR’s  2007 Hospital Preparedness Program guidance specifically authorized  states to use funds on activities such as the development of a fully  operational electronic medical volunteer registry in accordance with  ESAR-VHP guidance and the establishment of alternate care sites. We  cannot report state-specific funding for four key components—hospital  capacity, alternate care sites, electronic medical volunteer registries, and  altered standards of care—because state expenditure reports did not  disaggregate the dollar amount spent on specific activities related to these  components. During fiscal years 2003 through 2007, DHS’s Homeland  Security Grant Program also awarded the states funds that were used for a  broad variety of emergency preparedness activities and may have included  medical surge activities. However, most of these DHS grant funds were not  targeted to medical surge activities, and states do not report the dollar  amounts spent on these activities.
section_title: Guidance to Prepare for Medical Surge
paragraphs: The federal government developed, or contracted with experts to develop,  guidance for states to use in preparing for medical surge. DHS developed  overarching guidance, including the National Preparedness Guidelines  and the Target Capabilities List. The National Preparedness Guidelines  describes the tasks needed to prepare for a medical surge response to a  mass casualty event, such as a bioterrorist event or natural disaster, and  establishes readiness priorities, targets, and metrics to align the efforts of  federal, state, local, tribal, private-sector, and nongovernmental entities.  The Target Capabilities List provides guidance on building and  maintaining capabilities, such as medical surge, that support the National  Preparedness Guidelines. The medical surge capability includes activities  and critical tasks needed to rapidly and appropriately care for the injured  and ill from mass casualty events and to ensure that continuity of care is  maintained for non-incident-related injuries or illnesses.
In addition, ASPR provided states with specific guidance related to  preparing for medical surge in a mass casualty event, including annual  guidance for its Hospital Preparedness Program cooperative agreements,  guidance for developing ESAR-VHP-compliant electronic medical  volunteer registries, and guidance to develop a hospital bed tracking  system. The Hospital Preparedness Program cooperative agreement  guidance included activities to assist states in following DHS’s guidelines  and meeting its targets. ASPR’s ESAR-VHP guidelines provide states with  common definitions, standards, and protocols, which can aid in forming a  national network to facilitate the deployment of medical volunteers for  any emergency among states. For example, ESAR-VHP registration  guidelines categorize medical volunteers by profession, ranging from  physicians to mental health counselors. ESAR-VHP guidelines also include  four different levels of credentialing based on verification of each  volunteer’s qualifications. ASPR provided guidance to states for the  Hospital Available Beds for Emergencies and Disasters (HAvBED) system,  which is an inpatient bed tracking system designed to allow emergency  response entities to know where and what type of additional hospital beds  are available, in order to know which hospitals still have capacity to  receive patients. HAvBED reports the number of beds vacant/available at  the aggregate state level to HHS. To enhance consistency among state- reported data, HAvBED provides standard definitions of beds and data  elements each system must incorporate when reporting bed availability  during a mass casualty event.
Additionally, HHS worked through AHRQ and contracted with nonfederal  entities to develop publications for states to use when preparing for  medical surge. For example, AHRQ published the document Mass Medical  Care with Scarce Resources: A Community Planning Guide to provide  states with information that would help them in their efforts to prepare for  medical surge, such as specific circumstances they may face in a mass  casualty event. This publication notes that the state may be faced with  allocating medical resources during a mass casualty event, such as  determining which patients will have access to mechanical ventilation.  The publication recommends that the states develop decision-making  guidelines on how to allocate these medical resources. The RAND  Corporation developed the publication Learning from Experience: The  Public Health Response to West Nile Virus, SARS, Monkeypox, and  Hepatitis A Outbreaks in the United States, which provides states with  information on challenges that they may face in a disease outbreak or  bioterrorist attack. AHRQ also published Reopening Shuttered Hospitals  to Expand Surge Capacity, which contains an action checklist that can be  used by states and local entities to identify organizations that have an  interest or responsibility in preparing for medical surge, and to determine  what resources each could provide. (See app. III for a list of federal  guidance.)
section_title: Other Federal Assistance to Prepare for Medical Surge
paragraphs: To support states’ efforts to prepare for medical surge, the federal  government also provided other assistance such as conferences and  electronic bulletin boards for states to use in preparing for medical surge.  States were required to attend annual conferences for Hospital  Preparedness Program cooperative agreement recipients, where ASPR  provided forums for discussion of medical surge issues. (See app. III for a  list of federal conferences.) Additionally, ASPR’s Web site contained links  to related published documents, and states were given access to an ASPR- operated electronic bulletin board to communicate with other states on  medical surge issues related to the Hospital Preparedness Program.  Furthermore, ASPR project officers and CDC subject matter experts were  available to provide assistance to states on issues related to medical surge.  For example, CDC’s Division of Healthcare Quality Promotion developed  cross-sector workshops for local communities to bring their emergency  management, medical, and public health officials together to focus on  emergency planning issues, such as developing alternate care sites.
section_title: Many States Have Made Efforts to Increase Hospital Capacity, Plan for Alternate Care Sites, and Develop Electronic Medical Volunteer Registries, but Fewer Have Planned for Altered Standards of Care
paragraphs: Many states have made efforts related to three of the key components for  preparing for medical surge, that is, increasing hospital capacity, planning  for alternate care sites, and developing electronic medical volunteer  registries, but fewer have implemented the fourth, planning for altered  standards of care. More than half of the 50 states were meeting or close to  meeting the criteria for the five medical-surge-related sentinel indicators  for hospital capacity. In our 20-state review, we found that all were  developing bed reporting systems and almost all of the states with DOD  and VA hospitals were engaging in various levels of coordination with  those hospitals in an effort to expand their hospital capacity. Of the 20  states, 18 reported that they were in the process of selecting alternate care  sites that used either fixed or mobile medical facilities. Additionally, 15 of  the 20 states had begun registering volunteers in electronic medical  volunteer registries. However, only 7 of the 20 states had adopted or were  drafting altered standards of care for specific medical interventions to be  used in response to a mass casualty event.
subsections: section_title: All States Were Making Efforts to Expand Hospital Capacity
paragraphs: More than half of the states met or were close to meeting the criteria for  the five surge-related sentinel indicators for hospital capacity that we  reviewed from the Hospital Preparedness Program 2006 midyear progress  reports, the most recent available data at the time of our analysis. (See  table 1 for the five sentinel indicators and the associated criteria.) Twenty- four of the states reported that all of their hospitals were participating in  the state’s program funded by the ASPR Hospital Preparedness Program,  with another 14 states reporting that 90 percent or more of their hospitals  were participating. Forty-three of the 50 states have increased their  hospital capacity by ensuring that at least one health care facility in each  defined region could support initial evaluation and treatment of at least 10  patients at a time (adult and pediatric) in negative pressure isolation  within 3 hours of an event. Regarding individual hospitals’ isolation  capabilities, 32 of the 50 states met the requirement that all hospitals in the  state that participate in the Hospital Preparedness Program be able to  maintain at least one suspected highly infectious disease case in negative  pressure isolation; another 10 states had that capability in 90 to 99 percent  of their participating hospitals. Thirty-seven of the 50 states reported  meeting the criteria that within 24 hours of a mass casualty event, their  hospitals would be able to add enough beds to provide triage treatment  and stabilization for another 500 patients per million population; another 4  states reported that their hospitals could add enough beds for from 400 to  499 patients per million population. Finally, 20 states reported that all their  participating hospitals had access to pharmaceutical caches that were  sufficient to cover hospital personnel (medical and ancillary), hospital- based emergency first responders, and family members associated with  their facilities for a 72-hour period; another 6 states reported that from 90  to 99 percent of their participating hospitals had sufficient pharmaceutical  caches. (See app. IV for further information.)
In our further review of 20 states, all 20 states reported that they had  developed or were developing bed reporting systems to track their  hospital capacity—the first of four key components related to preparing  for medical surge. Eighteen of the 20 states reported that they had systems  in place that could report the number of available hospital beds within the  state. All 18 of these states reported that their systems met ASPR HAvBED  standards. For example, in early 2005 one state completed development  of a statewide Web-based bed tracking system designed to track the  emergency status of all health care facilities. The system has the capacity  to present information by individual facility as well as by county. The 2  states that reported that they did not have a system that could meet  HAvBED requirements said that they would meet the requirements by  August 8, 2008.
Our review also found that of the 10 states with DOD hospitals, 9 reported  coordinating with DOD hospitals to plan for emergency preparedness and  increase hospital capacity. For example, in one state DOD hospital  officials served on state-level emergency preparedness committees and  participated in training and exercises. The remaining state said it could not  report whether the DOD hospitals participated in such activities because  these activities were coordinated at the local level. Eight of the 10 states  also reported that DOD hospitals in their state would accept civilian  patients in the event of a mass casualty event if resources were available.  The 2 remaining states did not know whether their DOD hospitals would  accept civilian patients, although one of these states said that there had  been discussions about this possibility between the state and DOD.
Of the 19 states that have VA hospitals, all reported that at least some of  the VA hospitals took part in the states’ hospital preparedness programs or  were included in planning and exercises for medical surge. For example,  VA hospitals in one state were participating in state, regional, and local  planning for emergency preparedness along with other hospitals in an  effort to increase surge capacity and come closer to the state’s goal of 500  beds for every 1 million population, a VA official said. In another state, a  VA hospital was planning with state emergency preparedness officials and  DOD hospitals to prepare for any mass casualty event that could occur  during a major public event taking place in the state later that year. VA  officials stated that individual hospitals cannot precommit resources— specific numbers of beds and assets—for planning purposes, but can  accept nonveteran patients and provide personnel, equipment, and  supplies on a case-by-case basis during a mass casualty event. Twelve of  the 19 states reported that VA hospitals would accept or were likely to  accept nonveteran patients in the event of a medical surge if space were  available and veterans’ needs had been met. Four of the 19 states reported  that their VA hospitals would not accept nonveteran patients in the event  of a medical surge, 2 states reported that they did not know if the VA  hospitals would accept nonveteran patients, and 1 state reported that  some of its VA hospitals would take nonveteran patients and others would  not.
In planning to increase hospital capacity, most of the 20 states we  surveyed reported that they used federal guidance and technical  assistance. Eleven states reported that they used ASPR’s Hospital  Preparedness Program cooperative agreement guidance, and 9 states used  ASPR’s Medical Surge Capacity and Capabilities Handbook. Three states  also reported that they used CDC’s Public Health Emergency  Preparedness Program cooperative agreement guidance. In addition, 2  states reported that they consulted with ASPR project officers when  planning for hospital capacity.
section_title: Eighteen States Were Selecting Alternate Care Sites
paragraphs: Eighteen of the 20 states reported that they were in the process of  selecting alternate care sites, and the 2 remaining states reported that they  were in the early planning stages in determining how to select sites. Of the  18 states, 10 reported that they had also developed plans for equipping and  staffing some of the sites. For example, one state had developed standards  and guidance for counties to use when implementing fixed alternate care  sites and had stockpiled supplies and equipment for these sites. The  counties were responsible for identifying and operating these sites.  According to state officials, while most counties were still identifying fixed  sites, some counties had established memorandums of understanding with  various facilities, including churches, schools, military facilities, and  shopping malls. In addition, the state purchased three state-run mobile  medical facilities, each with 200 beds, which were stored in the northern,  central, and southern parts of the state. Another state, which expects  significant transportation difficulties during a natural disaster, had  acquired six mobile medical tent facilities of either 20 or 50 beds that were  stored at hospital facilities across the state. This state also planned to  identify fixed facility alternate care sites, which would provide medical  services to people who could not take care of themselves at home but did  not need to be in a hospital. Each of these fixed sites was expected to  serve 1,000 casualties. One of the 2 states that were in the early planning  stages was helping local communities formalize site selection agreements,  and the second state had drafted guidance for alternate care sites that was  expected to be released early in 2008.
Most states reported using AHRQ guidance when planning for alternate  care sites. For example, 18 states reported that they used AHRQ’s  guidance, such as Rocky Mountain Regional Care Model for Bioterrorist  Events, Alternate Care Site Selection Tool, and Reopening Shuttered  Hospitals to Expand Surge Capacity. A few states used other federal  guidance, such as DHS’s National Incident Management System and  National Disaster Management System guidance, when planning alternate  care sites. Five states also reported that they used DOD guidance when  planning alternate care sites, including DOD’s Modular Emergency  Medical System.
section_title: Fifteen States Had Begun Registering Volunteers in Electronic Medical Volunteer Registries
paragraphs: Fifteen of the 20 states reported that they had begun registering medical  volunteers and identifying their medical professions in an electronic  registry, and the remaining 5 states were developing their electronic  registries and had not registered any volunteers. For 2006, ESAR-VHP  guidance identified seven categories of health care professionals ranging  from physicians to mental health counselors that should be included in the  states’ registries. Of the 15 states that reported that they had begun  registering volunteers, 3 states had registered volunteers in more than  eight categories, 3 states had registered volunteers in five to seven  categories, and the remaining 9 states had registered volunteers in four or  fewer categories, often concentrating on nurses. Officials from 4 of the 5  remaining states that had not begun registering volunteers reported that  they anticipated registering volunteers by the spring or summer of 2008.  An official from the other state reported that state officials did not know  when they would begin to register volunteers.
Of the 15 states that reported they were registering volunteers, 12 reported  they had begun to verify the volunteers’ medical qualifications, though few  had conducted the verification to assign volunteers to the highest level,  Level 1. If a volunteer is assigned to Level 4, it means that the state has not  verified any medical qualifications, such as licenses or certifications in  medical subspecialties. Three of the 15 states had registered volunteers  solely at Level 4. Seven of the 12 states had credentialed some volunteers  no higher than Level 3, meaning they had verified the licenses of some of  the volunteers. For example, one state had verified the credentials and  assigned all of its 1,498 registered volunteers at Level 3. Another 3 of the  12 states had assigned volunteers to no higher than Level 2, meaning these  states had conducted additional verification of medical qualifications, such  as degrees. For example, one state had assigned its registered volunteer  nurses at Level 2. The remaining 2 states had assigned a small number of  volunteers at Level 1. For example, one state had assigned 2 of 955  volunteers at Level 1. At Level 1, all of a volunteer’s medical qualifications,  which identify their skills and capabilities, have been verified and the  volunteer is ready to provide care in any setting, including a hospital.
Nineteen of the 20 states reported that they used ASPR’s ESAR-VHP  Interim Technical and Policy Guidelines, Standards, and Definitions  when developing registries. Eight of the 20 states also reported that they  used information obtained from the annual ESAR-VHP conferences to help  develop their volunteer medical registry systems.
section_title: Seven of the 20 States Were Planning for Altered Standards of Medical Care
paragraphs: In our 20-state review of efforts related to the fourth key component, we  found that 7 states had adopted or were drafting altered standards of care  for specific medical issues. Three of the 7 states had adopted some altered  standards of care guidelines. For example, one state had prepared a  standard of care for the allocation of ventilators in an avian influenza  pandemic, which one state official reported would also be applicable  during other types of emergencies. Another state issued guidelines in  February 2008 for allocating scarce medical resources in a mass casualty  event that call for suspending or relaxing state laws covering medical care  and for explicit rationing of health care to save the most lives, and require  that the same allocation guidelines be used across the state. For example,  during a mass casualty event in this state, hospitals could ignore their  nurse-patient ratios and nurses could be assigned to jobs outside their  specific area of expertise. In addition, nonlicensed individuals, or retired  health care providers whose licenses had lapsed, could be recruited to  provide emergency care. For example, a nonmedical hospital employee  who had experience as a military medic could get an emergency credential  to stitch up wounds or start intravenous lines. According to an official, the  state had not completed all of the guidelines for allocation of scarce  resources that it planned to develop. The state recently convened a panel  of ethicists and providers to address which specific categories of patients  would receive scarce resources, such as vaccines and ventilators, when  shortages existed.
Of the 13 states that had not adopted or drafted altered standards of care,  11 states were beginning discussions with state stakeholders, such as  medical professionals and lawyers, related to altered standards of care,  and 2 states had not addressed the issue. One state reported that its state  health department planned to establish an ethics advisory board to begin  discussion on altered standards of care guidelines. Another state had  developed a “white paper” discussing the need for an altered standards of  care initiative and planned to fund a symposium to discuss this initiative.
Six of the seven states that had adopted or were drafting altered standards  of care guidelines reported using AHRQ documents, such as Altered  Standards of Care in Mass Casualty Events and Mass Medical Care with  Scarce Resources: A Community Planning Guide. Officials from one  state reported that they had also used CDC documents and the federal  government’s pandemic influenza Web site when planning for altered  standards of care.
section_title: States Reported Concerns Related to All Four Key Components When Preparing for Medical Surge
paragraphs: While the Hospital Preparedness Program has been operating since 2002,  state officials in the 20 states we surveyed reported that they faced  continuing challenges in preparing for medical surge in a mass casualty  event. Even though many states have made efforts to increase hospital  capacity, provide care at alternate care sites, identify and use medical  volunteers, and develop appropriate altered standards of care, they  expressed concerns related to all four of these key components of medical  surge. State officials also noted concerns related to programmatic and  regulatory issues involved in preparing for medical surge in a mass  casualty event.
subsections: section_title: Hospital Capacity Concerns
paragraphs: State officials raised several concerns related to their ability to increase  hospital capacity, including maintaining adequate staffing levels during  mass casualty events, a problem that was more acute in rural  communities. While 19 of 20 states we surveyed reported that they could  increase numbers of hospital beds in a mass casualty event, some state  officials were concerned about staffing these beds because of current  shortages in medical professionals, including nurses and physicians. Some  state officials reported that their states faced problems in increasing  hospital capacity because many of their rural areas had no hospital or  small numbers of medical providers. For example, officials from a largely  rural state reported that in many of the state’s medically underserved  areas hospitals currently have vacant beds because they cannot hire  medical professionals to staff them. In addition, these officials reported  that because their hospitals did not provide pediatric intensive care or  burn care services and instead transferred these patients to neighboring  states, the state might not be able to provide these services during a mass  casualty event.
State officials also reported that as time passed and no mass casualty  events occurred, increasing hospital capacity for a mass casualty event  seemed to be a waning priority for hospital chief executive officers. State  officials reported that it was difficult to continue to engage private-sector  hospital chief executive officers in emergency preparedness activities at a  time when these hospitals were facing day-to-day financial problems. For  example, officials from one state reported that hospitals in the state were  consolidating and closing, and officials from another state reported that  fewer hospitals were applying for ASPR Hospital Preparedness Program  funds. Officials from two other states reported that progress in preparing  emergency plans had slowed, especially for the smaller rural facilities,  because the Hospital Preparedness Program allows states to use these  funds to hire staff to assist with emergency planning but prohibits  hospitals from doing so. According to officials from one of these states,  hospital staff have had limited time to spend on emergency planning  activities because they must first attend to the operational needs of the  hospital.
section_title: Alternate Care Site Concerns
paragraphs: Some state officials reported that it was difficult to identify appropriate  fixed facilities for alternate care sites. Officials from two states reported  that some small, rural communities had few facilities that would be large  enough to house an alternate care site. Officials from some states also  reported that some of the facilities that could be used as alternate care  sites had already been allocated for other emergency uses, such as  emergency shelters.
State officials also reported concerns about reimbursement for medical  services provided at alternate care sites, which are not accredited health  care facilities. During the response to Hurricane Katrina, the Secretary of  HHS waived a number of statutory and regulatory requirements related to  medical care, and this waiver allowed for reimbursement of medical care  provided in alternate care sites. However, officials from several states  said that hospitals would prefer to know ahead of time under what  circumstances they would receive reimbursement from the Centers for  Medicare & Medicaid Services (CMS) for medical care provided in  alternate care sites during a mass casualty event. State officials said that  having such information would make planning and exercising easier and  more realistic. CMS officials told us it would be very difficult to provide  specific guidance that would apply to all medical surge events and that the  agency preferred to issue guidance on a case-by-case basis following visits  to alternate care sites by CMS or Joint Commission officials during the  emergency. For example, after Hurricane Katrina, CMS officials visited  alternate care sites and the Secretary of HHS relaxed reimbursement  requirements for medical care provided in a hospital parking lot, the  convention center, and a department store.
State officials also told us they were unclear how certain federal laws and  regulations that relate to medical care—specifically, the privacy rule  issued by HHS under the Health Insurance Portability and Accountability  Act of 1996 (HIPAA) and the Emergency Medical Treatment and Labor  Act (EMTALA)—would apply in a mass casualty event, especially if the  care were provided in an alternate care site and not a hospital. EMTALA  requires hospital emergency rooms at Medicare-participating hospitals to  screen and treat for emergency medical conditions all individuals who  seek treatment. The HIPAA privacy rule prohibits the unauthorized  disclosure of individually identifiable health information by health care  providers and certain other entities. The Social Security Act authorizes  the Secretary of HHS to waive EMTALA and certain requirements under  the HIPAA privacy rule during national emergencies, such as a mass  casualty event. Federal guidance published in 2006 describes  circumstances where provisions related to emergency treatment and  privacy protections were temporarily suspended. AHRQ’s publication  Providing Mass Medical Care with Scarce Resources: A Community  Planning Guide states that requiring hospitals to adhere to EMTALA  requirements during a mass casualty event could be unworkable because  of the large number of casualties. It notes that during Hurricane Katrina,  HHS temporarily suspended the application of EMTALA in affected  regions. This allowed hospitals to provide individuals’ medical screening  examination at, or transfer them to, alternate care sites, such as a  convention center and department store. During Hurricane Katrina, HHS  also temporarily relaxed the sanctions and penalties arising from  noncompliance with certain provisions of the HIPAA privacy rule,  including the requirements to obtain a patient’s agreement to speak with  family members or friends. HHS provided details of these waivers on its  Hurricane Katrina Web site.
section_title: Electronic Medical Volunteer Registry Concerns
paragraphs: Some states reported that medical volunteers might be reluctant to join a  state electronic medical volunteer registry if it is used to create a national  medical volunteer registry. PAHPA requires ASPR to use the state-based  registries to create a national database. According to state officials, some  volunteers do not want to be part of a national database because they are  concerned that they might be required to provide services outside their  own state. Officials from one state reported that since PAHPA was  enacted, recruiting of medical volunteers was more difficult and that the  federal government should clarify whether national deployment is a  possibility. ASPR officials said that they would not deploy medical  volunteers nationally without working through the states.
Finally, some states expressed concerns about coordination among  programs that recruit medical volunteers for emergency response.  Officials from one state reported that federal volunteer registration  requirements for the Medical Reserve Corps (MRC) and the ESAR-VHP  programs had not been coordinated, resulting in duplication of effort for  volunteers. For example, the volunteers registered in the MRC units in that  state also were expected by the state to register in the state electronic  medical volunteer registry. Officials from a second state reported that a  volunteer for one program that recruits medical volunteers is often a  potential volunteer for another such program, which could result in  volunteers being double-counted. For example, an emergency medical  technician registered in the electronic medical volunteer registry may also  volunteer for an MRC unit, a Disaster Medical Assistance Team (DMAT),  and the American Red Cross. This may cause staffing problems in the  event of an emergency when more than one volunteer program is  activated.
section_title: Altered Standards of Care Concerns
paragraphs: Some state officials reported that they had not begun work on altered  standards of care guidelines, or had not completed drafting guidelines,  because of the difficulty of addressing the medical, ethical, and legal  issues involved. For example, HHS estimates that in a severe influenza  pandemic almost 10 million people would require hospitalization, which  would exceed the current capacity of U.S. hospitals and necessitate  difficult choices regarding rationing of resources. HHS also estimates that  almost 1.5 million of these people would require care in an intensive care  unit and about 740,000 people would require mechanical ventilation. Even  with additional stockpiles of ventilators, there would likely not be a  sufficient supply to meet the need. Since some patients could not be put  on a ventilator, and others would be removed from the ventilator,  standards of care would have to be altered and providers would need to  determine which patients would receive them. In addition, some state  officials reported that medical volunteers are concerned about liability  issues in a mass casualty event. Specifically, state officials reported that  hospitals and medical providers might be reluctant to provide care during  a mass casualty event, when resources would be scarce and not all  patients would be able to receive care consistent with established  standards. According to these officials, these providers could be subject to  liability if decisions they made about altering standards of care resulted in  negative outcomes. For example, allowing staff to work outside the scope  of their practice, such as allowing nurses to diagnose and write medical  orders, could place these individuals at risk of liability.
While some states reported using AHRQ’s Mass Medical Care with Scarce  Resources: A Community Planning Guide to assist them as they  developed altered standards of care guidelines, some states also reported  that they needed additional assistance. States said that to develop altered  standards of care guidelines they must conduct activities such as  collecting and reviewing published guidance and convening experts to  discuss how to address the medical, ethical, and legal issues that could  arise during a mass casualty event. Four states reported that, when  developing their own guidelines on the allocation of ventilators, they were  using guidance from another state. This state estimated that a severe  influenza pandemic would require nearly nine times the state’s current  capacity for intensive care beds and almost three times its current  ventilator capacity, which would require the state to address the rationing  of ventilators. In March 2006 the state convened a workgroup to consider  clinical and ethical issues in the allocation of mechanical ventilators in an  influenza pandemic. The state issued guidelines on the rationing of  ventilators that include both a process and an evaluation tool to determine  which patients should receive mechanical ventilation. The guidelines note  that the application of this process and evaluation tool could result in  withdrawing a ventilator from one patient to give it to another who is more  likely to survive—a scenario that does not explicitly exist under  established standards of care. Additionally, some states suggested that the  federal government could help their efforts in several ways, such as by  convening medical, public health, and legal experts to address the  complex issues associated with allocating scarce resources during a mass  casualty event, or by developing demonstration projects to reveal best  practices employed by the various states. Recently, the Task Force for  Mass Critical Care, consisting of medical experts from both the public and  the private sectors, provided guidelines for allocating scarce critical care  resources in a mass casualty event that have the potential to assist states  in drafting their own guidelines. The task force’s guidelines, which were  published in a medical journal in May 2008, provide a process for triaging  patients that includes three components—inclusion criteria, exclusion  criteria, and prioritization of care. The exclusion criteria include patients  with a high risk of death, little likelihood of long-term survival, and a  corresponding low likelihood of benefit from critical care resources. When  patients meet the exclusion criteria, critical care resources may be  reallocated to patients more likely to survive.
section_title: Other Programmatic and Regulatory Concerns
paragraphs: Many state officials raised concerns about other federal programmatic and  regulatory challenges, such as program funding cycles, decreased federal  funding for hospital emergency preparedness, and new requirements for  state matching funds. State officials reported that ASPR’s Hospital  Preparedness Program’s single-year funding cycles had made planning and  operating state emergency preparedness programs challenging, in part  because it is difficult to plan and implement program activities in a single  year. One state official suggested that using a 3-year funding cycle for the  Hospital Preparedness Program would allow for long-term planning with  more realistic work plans. It would also allow for more time for program  development and less time spent on program administration. ASPR  officials said that they were aware of the concern and were considering a  transition to a multiyear funding cycle beginning in 2009. Another concern  expressed by some state officials was that federal funding for ASPR’s  Hospital Preparedness Program had decreased while program  requirements had increased, making it difficult for states to plan for  maintenance of emergency preparedness systems, meet new requirements,  and replace expired supplies. Hospital Preparedness Program funds  decreased about 18 percent from fiscal year 2004 to fiscal year 2007.  Finally, many state officials were concerned about the new requirement  for matching funds. Beginning in fiscal year 2009, states that want to  receive ASPR’s Hospital Preparedness Program funds will have to match   5 percent of the federal funds with either state funds or in-kind  contributions.
section_title: Conclusions
paragraphs: Though states have begun planning for medical surge in a mass casualty  event, only 3 of the 20 states in our review have developed and adopted  guidelines for using altered standards of care. HHS has provided broad  guidance that establishes a framework and principles for states to use  when developing their specific guidelines for altered standards of care.  However, because of the difficulty in addressing the related medical,  ethical, and legal issues, many states are only beginning to develop such  guidelines for use when there are not enough resources, such as  ventilators, to care for all affected patients. In a mass casualty event, such  guidelines would be a critical resource for medical providers who may  have to make repeated life-or-death decisions about which patients get or  lose access to these resources—decisions that are not typically made in  routine circumstances. Additionally, these guidelines could help address  medical providers’ concerns about ethics and liability that may ensue  when negative outcomes are associated with their decisions. In its role of  assisting states’ efforts to plan for medical surge, HHS has not collected  altered standards of care guidelines that some states and medical experts  have developed and made them available to other states. Once a mass  casualty event occurs, difficult choices will have to be made, and the more  fully the issues raised by such choices are discussed prior to making them,  the greater the potential for the choices to be ethically sound and  generally accepted.
section_title: Recommendation for Executive Action
paragraphs: To further assist states in determining how they will allocate scarce  medical resources in a mass casualty event, we recommend that the  Secretary of HHS ensure that the department serve as a clearinghouse for  sharing among the states altered standards of care guidelines that have  been developed by individual states or medical experts.
section_title: Agency Comments and Our Evaluation
paragraphs: We requested comments on a draft of this report from HHS, DHS, DOD,  and VA. These agencies’ comments are reprinted in appendixes V, VI, VII,  and VIII, respectively.
In commenting on this draft, HHS said our report was a fair representation  of the progress that has been made to improve medical surge capacity.  HHS was silent regarding our recommendation that the department serve  as a clearinghouse for sharing among the states altered standards of care  guidelines developed by individual states or medical experts. HHS  provided technical comments, which we incorporated where appropriate.
In commenting on this draft, DHS concurred with our findings and raised  two issues. With regard to the phrase “altered standards of care,” DHS said  that the definition of standard of care implies that the standard does not  change but “rather it is the type, or level, of care that is altered,” and that  this distinction highlights the need to prepare the public “for a different  look to health care” in a mass casualty incident. We agree that efforts to  inform the public would be beneficial because of the need for enhanced  public awareness about how medical care might be delivered in an  emergency, but our report focused on addressing states’ concerns about  the medical, ethical, and legal issues involved in drafting altered standards  of care guidelines. DHS also characterized our recommendation as calling  for “passive guidance” and suggested that HHS may need to explore the  possibility of producing guidance to direct states’ discussion on rationing  of scarce resources. However, we believe a clearinghouse role is more  appropriate for HHS than a directive role because the delivery of medical  care is a state, local, and private function.
DOD concurred with our findings and conclusions. VA concurred with our  findings and said that inconsistencies from state to state regarding VA  medical centers’ stance toward treating nonveterans in an emergency stem  from the centers’ varying capabilities to provide emergency medical  treatment. VA said, for example, that not all medical centers provide  emergency services or have the same level of emergency supplies.  Nevertheless, VA confirmed its authority to provide care in emergency  situations and specifically acknowledged that it is authorized to provide  emergency care to nonveterans on a humanitarian basis. Finally, VA also  highlighted its federal role in responding to disasters under Emergency  Support Function #8, the Robert T. Stafford Disaster Relief and  Emergency Assistance Act, and the National Response Framework, which  was beyond the scope of our report.
As arranged with your offices, unless you release its contents earlier, we  plan no further distribution of this report until 30 days after its issuance  date. At that time, we will send copies of this report to the Secretary of  HHS and other interested parties. We will also make copies available to  others on request. In addition, the report will be available at no charge on  the GAO Web site at http://www.gao.gov.
If you or your staffs have any questions about this report or need  additional information, please contact me at (202) 512-7114 or  bascettac@gao.gov. Contact points for our Offices of Congressional  Relations and Public Affairs may be found on the last page of this report.  Major contributors to this report were Karen Doran, Assistant Director;  Jeffrey Mayhew; Roseanne Price; Lois Shoemaker; and Cherie’ Starck.
section_title: Appendix I: Fifteen Hospital Preparedness Program 2006 Sentinel Indicators
subsections: section_title: 2. Total number of participating hospitals statewide.
paragraphs: 4.   Number of beds statewide, above the current daily staffed bed capacity, that awardee is capable of surging beyond within   5.   Number of participating hospitals statewide that have access to pharmaceutical caches sufficient to cover hospital personnel     (medical and ancillary), hospital-based emergency first responders and family members associated with their facilities for a     72-hour period.   6.   Number of participating hospitals statewide that have the capacity to maintain at least one suspected highly infectious disease   7.   Number of awardees’ defined regions that have regional facilities to support the initial evaluation and treatment of at least 10 adult    and pediatric patients at a time in negative pressure isolation within 3 hours post-event.  8.   Number of ambulatory and nonambulatory persons that can be decontaminated within a 3-hour period, statewide.  9.   Number of health care personnel, statewide, trained through competency-based programs.  10. Number of hospital lab personnel, statewide, trained in the protocols for referral of clinical samples and associated information.  11. Functional state-based ESAR-VHP system in place that allows qualified, competent volunteer health care professionals to         register for work in hospitals or other facilities during an emergency situation.  12. Number of volunteer health professionals by discipline and credentialing level currently registered in the state-based         ESAR-VHP system.   13. Number of drills conducted during the fiscal year 2006 budget period that included hospital personnel, equipment, or facilities.  14. Number of tabletop exercises conducted during the fiscal year 2006 budget period that included hospital personnel, equipment,         or facilities.  15. Number of functional exercises conducted during the fiscal year 2006 budget period that included hospital personnel, equipment,        or facilities.
The five sentinel indicators that were analyzed in this report for hospital capacity are 2, 4, 5, 6, and 7.
section_title: Appendix II: Scope and Methodology
paragraphs: To determine what assistance the federal government has provided to help  states prepare their regional and local health care systems for medical  surge in a mass casualty event, particularly related to four key  components—hospital capacity, alternate care sites, electronic medical  volunteer registries, and altered standards of care—we reviewed and  analyzed national strategic planning documents and identified links among  federal policy documents on emergency preparedness. We also reviewed  and analyzed studies and reports related to medical surge capacity issued  by the Congressional Research Service, the Department of Health and  Human Services’ (HHS) Office of Inspector General, the Agency for  Healthcare Research and Quality (AHRQ), the Centers for Disease Control  and Prevention (CDC), the Office of the Assistant Secretary for  Preparedness and Response (ASPR), the Joint Commission, and other  experts. In addition, we obtained and reviewed documents from ASPR to  determine the amount of funds awarded to states through its Hospital  Preparedness Program’s cooperative agreements. We did not review  funding documents from the Department of Homeland Security’s (DHS)  Homeland Security Grant Program because the agency does not track the  dollar amount spent on medical surge activities. We interviewed officials  from ASPR, CDC, and DHS to identify and document criteria and guidance  given to state and local entities to plan for medical surge and to learn how  federal funds were awarded and utilized.
To determine what states have done to prepare for medical surge in a  mass casualty event, particularly related to four key components, we  obtained and analyzed the 2006 and 2007 ASPR Hospital Preparedness  Program cooperative agreement applications and 2006 midyear progress  reports (the most current available information—generally effective  through March 2007—at the time of our data collection) for the 50 states.  We also reviewed the 15 sentinel indicators for the Hospital Preparedness  Program. We analyzed the 5 medical-surge-related sentinel indicators for  which criteria to evaluate performance were identified and which were  reported by the states in their 2006 midyear progress reports. Although  ASPR’s 2006 guidance for these reports does not provide specific criteria  with which to evaluate performance on these indicators, we identified  criteria to analyze the data provided for 5 of them from either ASPR’s  previous program guidance or DHS’s Target Capabilities List, which  includes requirements related to preparing for medical surge. All 5 of the  medical-surge-related sentinel indicators we analyzed were related to one  of the four key components—hospital capacity. See appendix I for a list of  the 15 sentinel indicators. In addition, we obtained and reviewed 20 states’  emergency preparedness planning documents relating to medical surge  and interviewed state officials from these states regarding their activities  related to hospital capacity, alternate care sites, electronic medical  volunteer registries, and altered standards of care. We also interviewed  these state officials to determine what federal guidance or tools they used  and to identify the Department of Defense (DOD) and the Department of  Veterans Affairs (VA) hospitals’ participation in state planning. Finally, we  obtained and reviewed DOD and VA policies and interviewed officials to  further understand their policies regarding participation with state and  local entities in emergency preparedness planning and responding to mass  casualty events.
To determine what concerns states identified as they prepared for medical  surge in a mass casualty event, we interviewed emergency preparedness  officials from the 20 states and focused our questions on their efforts  related to four key components of medical surge we identified. We also  asked what further assistance states might need from the federal  government to help prepare their health care systems for medical surge.
We did not validate the sentinel indicator data the 50 states reported to  ASPR; however, if data for specific indicators were missing or obviously  incorrect (e.g., a percentage was greater than 100 percent), we contacted  state officials for clarification. We did not examine the accuracy of other  self-reported information contained in the midyear progress reports or  Hospital Preparedness Program applications from the 20 states we  reviewed. During interviews with officials from the 20 states, we discussed  the completeness of information provided in their progress reports and  applications about four key components related to preparing for medical  surge. For each interview, we used a question set that contained open- ended questions. The state emergency preparedness officials we  interviewed provided varying levels of detail to answer our questions.  Thus our information from these interviews is illustrative and is intended  to provide a general description of what the 20 states have done to prepare  for medical surge in a mass casualty event and is not generalizable to all 50  states. We conducted our work from May 2007 through May 2008 in  accordance with generally accepted government auditing standards.
section_title: Appendix III: Hospital Preparedness Program Funding and Medical Surge Guidance and Conferences
paragraphs: Tables 2, 3, and 4 provide information on ASPR’s Hospital Preparedness  Program funding and on guidance and other assistance for states to use in  preparing for medical surge.
section_title: Appendix IV: Data for the Five Surge-Related Sentinel Indicators for Hospital Capacity from the Hospital Preparedness Program
paragraphs: Figures 1 through 5 provide data for the five surge-related sentinel  indicators for hospital capacity from ASPR’s Hospital Preparedness  Program 2006 midyear progress reports.
section_title: Appendix V: Comments from the Department of Health and Human Services
section_title: Appendix VI: Comments from the Department of Homeland Security
section_title: Appendix VII: Comments from the Department of Defense
section_title: Appendix VIII: Comments from the Department of Veterans Affairs