The resources that hospitals and their emergency departments would require for responding to a large-scale bioterrorist attack are far greater than those needed for everyday performance. The specific equipment, supplies, and facilities needed could vary depending upon what type of attack occurred, but many scenarios anticipate that the demand for health care could quickly outstrip the ability of hospitals to respond. For example, the TOPOFF 2000 exercise testing terrorism preparedness included a bioterrorism scenario of an attack using pneumonic plague released at a public event in a single location in one city. In this exercise, officials found that by the third day following the covert release, 500 persons with symptoms had been reported and antibiotic and ventilator shortages were beginning to occur. By the end of this day, nearly 800 cases were identified and over 100 persons had died. In each of the succeeding 2 days, the situation worsened and medical care in the city was described as beginning to shut down, with insufficient hospital staff, beds, ventilators, and drugs. At the conclusion of the exercise, 1 week after the attack, an estimated 3,700 cases of plague had been reported, with 950 to 2,000 deaths, including cases in other cities and abroad. In the early stages of the epidemic, hospitals were seeing 2 to 3 times their normal volume of patients and later in the exercise up to 10 times normal volumes were arriving at hospitals. Hospitals were not able to effectively isolate patients to prevent the spread of the disease to hospital staff. In order to be adequately prepared for bioterrorism, hospitals would need to have several basic capabilities, whether they possess them directly or have access to them through regional agreements. Plans that describe how hospitals would work with state and local officials to manage and coordinate an emergency response would need to be in place and to have been tested in an exercise, both at the state and local levels and at the regional level. Regional plans can help address capacity deficiencies by providing for the sharing, among hospitals and other community and state agencies and organizations, of resources that, while adequate for everyday needs, may be in short supply on a local level in an emergency. In addition, hospitals would need to be able to communicate easily with all organizations involved in the response as events unfold and critical information is acquired. Staff would need to be able to recognize and report to their state or local health department any illness patterns or diagnostic clues that might indicate an outbreak of a disease caused by a biological agent likely to be used by a terrorist. Finally, hospitals would need to have the capacity and staff necessary to treat large numbers of severely ill patients and limit the spread of infectious disease. They would need adequate stores of equipment and supplies, including medications, personal protective equipment, quarantine and isolation facilities, and air handling and filtration equipment. Many of the capabilities required for responding to a large-scale bioterrorist attack are also required for response to naturally occurring disease outbreaks. Such a "dual-use" response infrastructure improves the capacity of local public health agencies to respond to all hazards. For example, a large-scale outbreak of Severe Acute Respiratory Syndrome (SARS) would require many of the same capabilities that would be needed to respond to an intentionally caused epidemic. Prior to our survey, efforts had been made by organizations to assist hospitals in preparing for bioterrorism. For example, the American Hospital Association distributed a checklist to help hospitals describe and assess their state of preparedness for chemical and biological incidents. This checklist covered, for example, emergency response plans for hospital operations during a biological or chemical disaster; emergency preparedness training of the workers; and the hospital's ability to increase its capacity--for example, in terms of such items as ventilators and decontamination equipment--in the event of a large number of patients seeking care. Another organization, the Association for Professionals in Infection Control and Epidemiology, developed a mass casualty disaster plan checklist for health care facilities, including hospitals. This checklist included disease surveillance activities, communication systems, plans for receiving and treating casualties, and plans for the organized discharge of nonemergency patients on short notice. Nevertheless, in our April 2003 report, we noted the general lack of guidance on what capacities hospitals should have to be prepared for bioterrorism. We also noted that efforts to improve hospitals' bioterrorism response capacities must be mindful that hospitals face multiple challenges, including having to prepare for other types of disasters and continuing to meet the everyday needs of cities for emergency care. In that report, among other things, we recommended that the Department of Health and Human Services (HHS) develop specific benchmarks that define adequate preparedness for a bioterrorist attack and can be used to guide preparedness efforts. Since our survey, there have been continuing efforts to assist hospitals in bioterrorism preparedness. For example, the Joint Commission on Accreditation of Healthcare Organizations released a report in 2003 on strategies for creating and sustaining communitywide preparedness systems for health care organizations, including hospitals. The report outlined critical issues to be addressed in developing communitywide preparedness and discussed federal and state responsibilities for eliminating barriers to preparedness and for facilitating and sustaining hospital and community-based emergency preparedness. It called for hospitals to address the full range of potential disasters, including terrorism, in their planning and to be aware of the specific hazards applicable to their communities. The federal government has also provided assistance for improving the bioterrorism preparedness of hospitals. In January 2002 HHS announced the availability of funding for that purpose. The Bioterrorism Hospital Preparedness Program, administered by HHS's Health Resources and Services Administration (HRSA), provided funding in fiscal year 2002 of approximately $125 million through cooperative agreements to states and eligible municipalities to enhance the capacity of hospitals and associated health care entities to respond to bioterrorism. These noncompetitive cooperative agreements covered two phases. In the first phase, states and municipalities applying for this funding were required to develop a needs assessment for a comprehensive bioterrorism preparedness program for hospitals and other health care entities, such as community health centers, and an implementation plan, as well as to begin initial implementation of the plan. Applications for the first phase were due to HHS by February 25, 2002, and funding for this phase, approximately $25 million, was awarded shortly after receipt of applications. For the second phase, jurisdictions were required to submit more detailed implementation plans, in which they addressed three "critical benchmarks," including a regional hospital plan for dealing with a potential epidemic involving at least 500 patients. In addition, applicants were to address four top-priority planning areas: medications and vaccines; personal protection, quarantine, and decontamination; communications; and biological disaster drills. Applications for the second phase were due April 15, 2002, and the additional funding, approximately $100 million, was awarded after HHS's review and approval of the plans. In March 2003, HHS announced that HRSA's National Bioterrorism Hospital Preparedness Program would provide funding in fiscal year 2003 of approximately $498 million through cooperative agreements to states and eligible municipalities. In response to our recommendations concerning additional guidance, HHS noted that it is developing some additional guidelines and templates to assist in preparedness efforts. In addition, the federal government has established a stockpile of pharmaceuticals, antidotes, and medical supplies that can be delivered to the site of a bioterrorist (or other) attack. This Strategic National Stockpile has recently been expanded and HHS disclosed that it is planning to purchase 2,700 ventilators by September 2003 to supplement those now available in the stockpile. These supplies could be deployed to the site of an attack within 12 to 36 hours following a declaration of an emergency. Most hospitals in urban areas across the country reported participating in basic planning and coordination activities for bioterrorism response. Although most hospitals reported providing at least some training to their personnel on identification and diagnosis of disease caused by biological agents considered likely to be used in a bioterrorist attack, only about half report they have conducted drills or exercises simulating response to a bioterrorist incident. Further, few reported having acquired the medical equipment to handle the large increase in the number of patients that would be likely to result from a bioterrorist incident. Our survey showed that hospitals have engaged in a variety of planning and coordination activities, with most having prepared an emergency response plan addressing bioterrorism; participated in a local, state, or regional interagency disaster preparedness committee; and made agreements with at least one other organization to share personnel or equipment in the event of a bioterrorist or other mass casualty incident. Four out of five hospitals reported having a written emergency response plan that specifically addresses bioterrorism (see fig. 1). Hospitals that had a plan were on average around 15 percent larger than those that did not in terms of number of staffed beds. Of those hospitals that reported not having such a plan, almost all were currently developing one. We asked hospitals whether certain elements were specified in their emergency response plan: contacting other response agencies and organizations in the event of a bioterrorist incident and managing various critical functions such as decontamination of victims. As shown in figure 2, of the hospitals that reported having an emergency response plan for bioterrorism, approximately 90 percent reported specifying in their plan to contact state and local government agencies, public health agencies, other hospitals, hazardous materials (HAZMAT) teams, emergency medical services (EMS), fire departments, or law enforcement. These entities would be critical to mounting a larger communitywide response, communicating with the public, investigating and controlling sources of the outbreak, transporting patients, maintaining order, and investigating those responsible for the bioterrorism. Hospitals that planned to contact HAZMAT teams or public health agencies were on average around 15 and 20 percent larger, respectively, than those that did not. There were no significant differences in average sizes of hospitals with respect to contacting any of the other entities. Approximately 75 percent of hospitals reported planning to contact public or private utilities, whose assistance could be needed to increase or maintain power supplies to critical equipment or to control water- or sewer-borne pathogens. Although establishing contact with other laboratories that could potentially provide additional capacity for overstretched hospital laboratories would be critical, the percentage of hospitals planning to make that link was lowest, at approximately 60 percent. Approximately 40 percent of hospitals reported specifying contacting all nine types of entities listed in figure 2. As shown in figure 3, most of the hospitals that reported having an emergency response plan for bioterrorism indicated that they specified in that plan how certain critical functions were to be managed. The functions specified by more than 87 percent of hospitals included providing for hospital security to control entry to and exit from all parts of the hospital; obtaining additional staff, supplies, and pharmaceuticals to increase the hospital's capacity to handle a surge of patients; or planning for mass evacuation of nonemergency patients on short notice. In general, larger hospitals had emergency response plans that covered more of these functions than the plans of smaller hospitals. Hospitals that reported addressing how to obtain additional pharmaceuticals for surge capacity, "worried well" management, and mass fatalities were on average around 15 percent larger than those that did not. There were no significant differences in average sizes of hospitals with respect to any of the other functions. Approximately 77 percent of the hospitals reported addressing the question of how to manage a large influx of the worried well and distinguish them from victims who may be in the early stages of illness. Approximately 50 percent of hospitals addressed the management of all of the critical functions listed in figure 3. Whether they had an emergency response plan addressing bioterrorism or not, more than 95 percent of hospitals reported participating in a local, state, or regional interagency disaster preparedness committee, task force, or working group. Most commonly, these committees also included representatives from city and county emergency medical services organizations, fire departments, city and county offices of emergency management, other local hospitals or medical institutions, city and county public health or health departments and agencies, and law enforcement organizations (see table 1). As we have previously reported, it was not until after September 11, 2001, that government and hospital officials came to view hospitals as an integral component in local planning for responding to a terrorist event. Another planning and coordination activity that hospitals reported on in our survey was their participation in agreements to share or provide resources in the event of a bioterrorist or other mass casualty incident. We asked about agreements at the hospital, city, county, state, and regional levels. The survey results indicated that hospitals mostly coordinated with other hospitals, about half coordinated with the local government, and about one-third coordinated at the state or regional level to provide or share resources. About 70 percent of hospitals reported that they had agreements, such as memoranda of understanding or mutual aid agreements, with other hospitals to provide or share personnel, equipment, or other resources (see fig. 4). Fewer (between 37 and 54 percent) hospitals had agreements with regional, state, county, or city organizations (fig. 4). In general, hospitals that had agreements with other organizations were larger than those that did not. Hospitals that had agreements with other hospitals or with city organizations were on average around 10 percent larger than hospitals that did not. Fewer than 20 percent of hospitals had agreements with entities at all five levels. Approximately 7 out of 10 hospitals reported that their staff had received training (services, courses, or self-learning materials) for identifying and diagnosing illness caused by all six biological agents that CDC has stated would be most likely to be used in a bioterrorist incident (see fig. 5). Hospitals that reported training activities for all of the biological agents were on average around 15 percent larger than hospitals that did not. A greater percentage of hospitals reported that staff had received training for anthrax or smallpox (around 90 percent or more) than for plague or botulism (approximately 80 percent) or tularemia or hemorrhagic fever viruses (approximately 70 percent). However, the extensiveness of the reported training cannot be determined from our survey. About half of all hospitals reported participating in drills or tabletop exercises simulating a biological attack during the past 2 years. Hospitals that reported participating in biological drills were on average around 20 percent larger than hospitals that did not. Of all of the hospitals that participated in biological drills or exercises, approximately 80 percent carried out these activities with other organizations. The availability of medical equipment needed for bioterrorism response varied greatly among hospitals, and hospitals reported that they did not have the capacity to respond to the large increase in the number of patients that would be likely to result from a bioterrorist incident with mass casualties (see table 2). For example, if a large number of patients were to arrive at a hospital with severe respiratory problems associated with anthrax or botulism, a comparable number of ventilators would be required to treat them. However, half of the hospitals had, per 100 staffed beds, fewer than six ventilators, three or fewer personal protective equipment (PPE) suits, fewer than four isolation beds, or the ability to handle fewer than six patients per hour through a 5-minute decontamination shower. More specifically, fewer than 31 percent of hospitals could handle 10 or more patients per hour through a 5-minute decontamination shower per 100 staffed beds, and fewer than 10 percent had 10 or more isolation beds per 100 staffed beds. Almost 40 percent of the hospitals had fewer than two PPE suits per 100 staffed beds, and almost 10 percent had fewer than two ventilators per 100 staffed beds. Hospital officials have told us that bioterrorism preparedness is expensive and they are reluctant to create capacity that is not needed on a routine basis and may never be needed at a particular facility. As concerns about bioterrorism have intensified over the past few years, hospitals across the nation have been working to increase their preparedness for responding to such events. The staff and equipment that hospitals would require to respond to a bioterrorist attack with mass casualties are far greater than what are needed for everyday performance. Meeting those needs fully could be extremely difficult because bioterrorism preparedness is expensive and hospitals are reluctant to create capacity that is not needed on a routine basis and may never be used. In addition, along with a hospital's ability to meet the routine needs of the community, needs for additional capacity for responding to bioterrorism emergencies must be balanced with the need to be prepared for all types of emergencies. Hospital officials have recognized that their facilities are an essential component of our nation's bioterrorism preparedness and have begun planning and training efforts to increase their response capacity. Most hospitals, however, still lack equipment, medical stockpiles, and quarantine and isolation facilities for even a small- scale response. The additional funding that is to be provided under the National Bioterrorism Hospital Preparedness Program in fiscal year 2003 can be used to help hospitals address these issues. The additional guidance from HHS, in response to our earlier recommendations, may also be helpful in assisting hospitals to better determine what specific response capacities they need to ensure. Representatives from the American Hospital Association provided oral comments on a draft of this report. The officials generally agreed with our findings and stated that this was a good and useful report providing helpful information on hospital preparedness. They commended us for the high response rate to the survey, stating that this provided a more comprehensive picture of hospital activities than was available elsewhere. The officials suggested that the report make greater reference to the lack of specific benchmarks for hospitals to use in planning, provide additional context on the range of possible events that hospitals must consider in their planning, and refer readers more specifically to prior GAO recommendations on bioterrorism preparedness. We have added additional material to clarify these points. The officials also provided technical remarks, which we have incorporated where appropriate. We are sending copies of this report to the Secretary of HHS, the Administrator of HRSA, and other interested officials. We will also provide copies to others upon request. In addition, the report will be available at no charge on GAO's Web site at http://www.gao.gov. If you or your staffs have any questions about this report, please call me at (202) 512-7119. Key contributors are listed in appendix III. This appendix describes the characteristics of the short-term, nonfederal, general medical and surgical hospitals in metropolitan statistical areas (MSA) in the United States that had emergency departments in 2000 that we surveyed, and summarizes results by state. We sent the questionnaires to 2,041 hospitals that met these criteria--20 did not have emergency departments in fiscal year 2001 or were closed, for a total of 2,021 hospitals. We obtained responses to the survey from 1,489 hospitals, for an overall response rate of about 74 percent. However, 7 of these hospitals did not return the section of the survey addressing emergency preparedness, leaving 1,482, for a response rate of about 73 percent for the questions of concern for the current report. We weighted responses to adjust for a lower response rate from investor-owned (for-profit) hospitals to provide estimates representative of the entire universe of 2,021 hospitals in MSAs. The following tables show selected survey information on the characteristics of the survey universe (table 3), response rates for hospitals by state for all states and the District of Columbia (table 4), planning and coordination activities (tables 5 through 8), and training activities (tables 9 and 10), for states that had at least 10 hospitals respond and a response rate of at least 50 percent (tables 4-10). All data in tables are weighted to provide estimates for the universe of 2,021 hospitals in MSAs. Between May and September 2002 we surveyed more than 2,000 short- term, nonfederal, general medical and surgical hospitals with emergency departments located in metropolitan statistical areas (MSAs). Survey hospitals were located in the 50 states and the District of Columbia. The survey questionnaire contained three parts. The first and second parts addressed emergency room functioning, and the third part addressed hospital preparedness for bioterrorism. We reported our survey findings on emergency room functioning in March 2003. We conducted our work between May 2002 and July 2003 in accordance with generally accepted government auditing standards. Of the initial universe of 2,041 hospitals that met the selection criteria, 18 had closed by 2002 and 2 did not have emergency departments in fiscal year 2001, resulting in a final universe of 2,021 hospitals. We sent our questionnaire to these hospitals and conducted follow-up mailings and telephone follow-up calls to nonrespondents. We obtained responses to the survey from 1,489 hospitals, for an overall response rate of about 74 percent. However, 7 of these hospitals did not return the section of the survey addressing emergency preparedness, leaving 1,482, for a response rate of about 73 percent for the questions of concern for the current report. We analyzed the response rates by hospital size, type of ownership, and teaching status to assess if there was differential response among various categories of hospitals. The only statistically significant disproportionate response was from for-profit hospitals. Therefore we weighted responses to adjust for a lower response rate from investor-owned (for-profit) hospitals to provide estimates representative of the entire universe of 2,021 hospitals in MSAs. Using the information provided by surveyed hospitals, we described the extent of emergency preparedness for bioterrorist incidents. We also examined the relationships between the extent of hospital bioterrorism preparedness and size of hospital as indicated by the number of inpatient staffed beds. Questions in the survey focused on preparedness to respond to a bioterrorist event. Some of the responses are applicable more broadly to preparedness for all types of terrorist events, as well as for natural disasters or naturally occurring disease outbreaks. However, because the focus of this work was bioterrorism preparedness, we did not ask more detailed questions on other types of preparedness. In addition to the contact named above, George Bogart, Jennifer Cohen, Robert Copeland, Susan Lawes, Deborah Miller, and Roseanne Price made key contributions to this report. Severe Acute Respiratory Syndrome: Established Infectious Disease Control Measures Helped Contain Spread, but a Large-Scale Resurgence May Pose Challenges. GAO-03-1058T. Washington, D.C.: July 30, 2003. Bioterrorism: Information Technology Strategy Could Strengthen Federal Agencies' Abilities to Respond to Public Health Emergencies. GAO-03-139. Washington, D.C.: May 30, 2003. SARS Outbreak: Improvements to Public Health Capacity Are Needed for Responding to Bioterrorism and Emerging Infectious Diseases. GAO-03-769T. Washington, D.C.: May 7, 2003. Smallpox Vaccination: Implementation of National Program Faces Challenges. GAO-03-578. Washington, D.C.: April 30, 2003. Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have Improved Public Health Response Capacity, but Gaps Remain. GAO-03-654T. Washington, D.C.: April 9, 2003. Bioterrorism: Preparedness Varied across State and Local Jurisdictions. GAO-03-373. Washington, D.C.: April 7, 2003. Hospital Emergency Departments: Crowded Conditions Vary among Hospitals and Communities. GAO-03-460. Washington, D.C.: March 14, 2003. Homeland Security: New Department Could Improve Coordination but Transferring Control of Certain Public Health Programs Raises Concerns. GAO-02-954T. Washington, D.C.: July 16, 2002. Homeland Security: New Department Could Improve Biomedical R&D Coordination but May Disrupt Dual-Purpose Efforts. GAO-02-924T. Washington, D.C.: July 9, 2002. Homeland Security: New Department Could Improve Coordination but May Complicate Priority Setting. GAO-02-893T. Washington, D.C.: June 28, 2002. Homeland Security: New Department Could Improve Coordination but May Complicate Public Health Priority Setting. GAO-02-883T. Washington, D.C.: June 25, 2002. Bioterrorism: The Centers for Disease Control and Prevention's Role in Public Health Protection. GAO-02-235T. Washington, D.C.: November 15, 2001. Bioterrorism: Review of Public Health Preparedness Programs. GAO-02-149T. Washington, D.C.: October 10, 2001. Bioterrorism: Public Health and Medical Preparedness. GAO-02-141T. Washington, D.C.: October 9, 2001. Bioterrorism: Coordination and Preparedness. GAO-02-129T. Washington, D.C.: October 5, 2001. Bioterrorism: Federal Research and Preparedness Activities. GAO-01-915. Washington, D.C.: September 28, 2001. West Nile Virus Outbreak: Lessons for Public Health Preparedness. GAO/HEHS-00-180. Washington, D.C.: September 11, 2000. Combating Terrorism: Need for Comprehensive Threat and Risk Assessments of Chemical and Biological Attacks. GAO/NSIAD-99-163. Washington, D.C.: September 14, 1999. Combating Terrorism: Observations on Biological Terrorism and Public Health Initiatives. GAO/T-NSIAD-99-112. Washington, D.C.: March 16, 1999.

Summary:
In the event of a large-scale infectious disease outbreak, as could be seen with a bioterrorist attack, hospitals and their emergency departments would be on the front line. Federal, state, and local officials are concerned, however, that hospitals may not have the capacity to accept and treat a sudden, large increase in the number of patients, as might be seen in a bioterrorist attack. In the Public Health Improvement Act that was passed in 2000, Congress directed GAO to examine preparedness for a bioterrorist attack. In this report GAO provides information on the extent of bioterrorism preparedness among hospitals in urban areas in the United States. To conduct this work, GAO surveyed over 2,000 urban hospitals and about 73 percent provided responses addressing emergency preparedness. The survey collected information on hospital preparedness for bioterrorism, such as data on planning activities, staff training, and capacity for response. While most urban hospitals across the country reported participating in basic planning and coordination activities for bioterrorism response, they did not have the medical equipment to handle the number of patients that would be likely to result from a bioterrorist incident. Four out of five hospitals reported having a written emergency response plan addressing bioterrorism, but many plans omitted some key contacts, such as other laboratories. Almost all hospitals reported participating in a local, state, or regional interagency disaster preparedness committee. In addition, most hospitals reported having provided at least some training to their personnel on identification and diagnosis of disease caused by biological agents considered likely to be used in a bioterrorist attack, such as anthrax or botulism. In contrast, fewer than half of hospitals have conducted drills or exercises simulating response to a bioterrorist incident. Hospitals also reported that they lacked the medical equipment necessary for a large influx of patients. For example, if a large number of patients with severe respiratory problems associated with anthrax or botulism were to arrive at a hospital, a comparable number of ventilators would be required to treat them. Yet half of hospitals reported having fewer than six ventilators per 100 staffed beds. In general, larger hospitals reported more planning and training activities than smaller hospitals. Representatives from the American Hospital Association provided oral comments on a draft of this report, which GAO incorporated as appropriate. They generally agreed with the findings.