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entitled 'Emergency Preparedness: States Are Planning for Medical 
Surge, but Could Benefit from Shared Guidance for Allocating Scarce 
Medical Resources' which was released on July 14, 2008.

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Report to Congressional Requesters: 

United States Government Accountability Office: 
GAO: 

June 2008: 

Emergency Preparedness: 

States Are Planning for Medical Surge, but Could Benefit from Shared 
Guidance for Allocating Scarce Medical Resources: 

GAO-08-668: 

GAO Highlights: 

Highlights of GAO-08-668, a report to congressional requesters. 

Why GAO Did This Study: 

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. 

What GAO Found: 

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. 

What GAO Recommends: 

GAO recommends that the Secretary of HHS ensure 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 was silent on GAO’s recommendation. HHS and the departments of 
Homeland Security, Defense, and Veterans Affairs concurred with GAO’s 
findings. 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-668]. For more 
information, contact Cynthia A. Bascetta at (202) 512-7114 or 
bascettac@gao.gov. 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

The Federal Government Has Provided States with Funding, Guidance, and 
Other Assistance to Prepare for Medical Surge: 

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: 

States Reported Concerns Related to All Four Key Components When 
Preparing for Medical Surge: 

Conclusions: 

Recommendation for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Fifteen Hospital Preparedness Program 2006 Sentinel 
Indicators: 

Appendix II: Scope and Methodology: 

Appendix III: Hospital Preparedness Program Funding and Medical Surge 
Guidance and Conferences: 

Appendix IV: Data for the Five Surge-Related Sentinel Indicators for 
Hospital Capacity from the Hospital Preparedness Program: 

Appendix V: Comments from the Department of Health and Human Services: 

Appendix VI: Comments from the Department of Homeland Security: 

Appendix VII: Comments from the Department of Defense: 

Appendix VIII: Comments from the Department of Veterans Affairs: 

Tables: 

Table 1: Medical-Surge-Related Sentinel Indicators for Hospital 
Capacity from Hospital Preparedness Program 2006 Midyear Progress 
Reports and Our Associated Criteria: 

Table 2: ASPR's Hospital Preparedness Program Funding by State, Fiscal 
Years 2002 through 2007: 

Table 3: Federal Guidance and Technical Assistance Published for States 
to Use in Preparing for Medical Surge: 

Table 4: Federal Conferences and Meetings with States That Provided 
Information to Prepare for Medical Surge: 

Figures: 

Figure 1: Hospital Participation in Individual States' Hospital 
Preparedness Programs: 

Figure 2: States Whose Regions Have the Capability to Treat at Least 10 
Patients at a Time in Negative Pressure Isolation: 

Figure 3: States with Participating Hospitals That Have Negative 
Pressure Isolation Capabilities: 

Figure 4: Number of Additional Surge Beds per Million Population That 
Can Be Added above Normal Capacity within 24 Hours: 

Figure 5: States Whose Participating Hospitals Have Sufficient 
Pharmaceuticals to Treat Hospital Personnel and Their Family Members: 

Abbreviations: 

AHRQ: Agency for Healthcare Research and Quality: 

ASPR: Office of the Assistant Secretary for Preparedness and Response: 

CDC: Centers for Disease Control and Prevention: 

CMS: Centers for Medicare & Medicaid Services: 

DHS: Department of Homeland Security: 

DMAT: Disaster Medical Assistance Team: 

DOD: Department of Defense: 

EMTALA: Emergency Medical Treatment and Labor Act: 

ESAR-VHP: Emergency System for Advance Registration of Volunteer Health 
Professionals: 

HAvBED: Hospital Available Beds for Emergencies and Disasters: 

HHS: Department of Health and Human Services: 

HIPAA: Health Insurance Portability and Accountability Act of 1996: 

HRSA: Health Resources and Services Administration: 

HSPD: Homeland Security Presidential Directive: 

MRC: Medical Reserve Corps: 

PAHPA: Pandemic and All-Hazards Preparedness Act: 

VA: Department of Veterans Affairs: 

[End of section] 

United States Government Accountability Office: Washington, DC 20548: 

June 13, 2008: 

Congressional Requesters: 

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[Footnote 
1] to respond to bioterrorism[Footnote 2] and other mass casualty 
events. [Footnote 3] In a mass casualty event the ability of local or 
regional health care systems to deliver services consistent with 
established standards of care[Footnote 4] 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[Footnote 
5] when hospital capacity is overwhelmed; (3) registering and 
credentialing volunteer medical professionals; and (4) planning for 
appropriate altered standards of care[Footnote 6] 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.[Footnote 7] 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.[Footnote 8] 
Under the federal plan for responding to emergencies,[Footnote 9] 
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.[Footnote 10] 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.[Footnote 
11] 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[Footnote 12]) for the 50 states.[Footnote 13] 

We also reviewed the 15 sentinel indicators from these reports. 
[Footnote 14] 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.[Footnote 15] (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. 

Results in Brief: 

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 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--for 
example, DHS's National Preparedness Guidelines and Target Capabilities 
List. In addition, ASPR annually provided specific guidance for its 
Hospital Preparedness Program awardees on preparing for medical surge, 
including activities to assist states in following DHS's guidelines and 
meeting its targets. AHRQ issued guidance on Reopening Shuttered 
Hospitals to Expand Surge Capacity, which contains a checklist that 
states and local entities can use to identify organizations that could 
provide more resources during a medical surge. In addition, ASPR 
project officers and CDC subject matter experts were available to 
provide assistance to states on issues related to medical surge. 

Many states have made efforts related to three of the key components of 
medical surge, that is, increasing hospital capacity, planning for 
alternate care sites, and developing electronic medical volunteer 
registries, but fewer have addressed the fourth component, planning for 
altered standards of care. 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 that we extracted from the 
Hospital Preparedness Program 2006 midyear progress reports. For 
example, 37 states reported that they could meet the criterion of being 
able to add enough beds to provide triage treatment and stabilization 
for at least 500 patients per million population within 24 hours of a 
mass casualty event, with another 4 states reporting that they could do 
so for from 400 to 499 patients per million population. In our 20-state 
review, we found that all were developing bed reporting systems and 
most were coordinating to various degrees with DOD and VA 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. For example, 
one state had purchased three mobile medical facilities, each with 200 
beds, to be located in different areas of the state. Additionally, 15 
of the 20 states had begun registering volunteers in electronic medical 
volunteer registries, and 14 of those states reported that they had 
begun to verify the volunteers' medical qualifications, though few had 
conducted the verification at the level that most completely identified 
volunteers' skills and capabilities for providing care in a hospital. 
However, fewer of the states--7 of the 20--had adopted or were drafting 
altered standards of medical care to be used in response to a mass 
casualty event. For example, one state had prepared standards of care 
guidelines for the allocation of ventilators in that state and another 
state issued guidelines in February 2008 that call for suspending or 
relaxing state laws covering medical care and for allocating health 
care to save the most lives. 

While the Hospital Preparedness Program has been operating since 2002, 
state officials in the 20 states we surveyed reported that they 
continued to face challenges in preparing for medical surge in a mass 
casualty event. They expressed concerns related to all four key 
components of medical surge. For example, some states reported that 
although they could increase numbers of hospital beds in a mass 
casualty event, they were concerned about staffing those beds because 
of current shortages in medical professionals, and some states 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 altered standards 
of care guidelines, or had not completed drafting guidelines, because 
of the difficulty of addressing the medical, ethical, and legal issues 
involved in making life-or-death decisions in advance of a disaster 
about which patients would get or lose access to scarce resources. 
Finally, state officials also noted concerns related to other issues 
involved in preparing for medical surge, such as decreased federal 
funding for hospital emergency preparedness. 

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. In 
commenting on a draft of this report, HHS was silent regarding our 
recommendation. HHS, DHS, DOD, and VA concurred with our findings. 

Background: 

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. 

Federal Responsibilities Relating to States' Preparedness for Medical 
Surge: 

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.[Footnote 16] 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,[Footnote 17] which provides funds annually to 62 entities--the 
50 states, 4 municipalities, 5 U.S. territories, and 3 Freely 
Associated States of the Pacific[Footnote 18]--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.[Footnote 19] 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. 

Key Components of Medical Surge in a Mass Casualty Event: 

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[Footnote 20] 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.[Footnote 21] 

* 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. 
[Footnote 22] 

The Federal Government Has Provided States with Funding, Guidance, and 
Other Assistance to Prepare for Medical Surge: 

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. 

Funding to Prepare for Medical Surge: 

From fiscal years 2002 through 2007, HHS awarded states about $2.2 
billion through ASPR's Hospital Preparedness Program[Footnote 23] to 
support activities to strengthen their hospital emergency preparedness 
capabilities, including medical surge goals and priorities.[Footnote 
24] (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. 

Guidance to Prepare for Medical Surge: 

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.[Footnote 25] 

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.[Footnote 26] 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.[Footnote 27] 

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.[Footnote 28] 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.) 

Other Federal Assistance to Prepare for Medical Surge: 

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. 

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: 

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. 

All States Were Making Efforts to Expand Hospital Capacity: 

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,[Footnote 29] the most recent available data at the 
time of our analysis.[Footnote 30] (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.) 

Table 1: Medical-Surge-Related Sentinel Indicators for Hospital 
Capacity from Hospital Preparedness Program 2006 Midyear Progress 
Reports and Our Associated Criteria: 

Sentinel indicator: Hospital participation: Total number of 
participating hospitals statewide; 
Criteria we used[A]: State reported that 100 percent of its hospitals 
were participating in state hospital preparedness programs supported by 
ASPR funding. 

Sentinel indicator: Regional negative pressure isolation:[B] Number of 
states' 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; 
Criteria we used[A]: State could identify at least one health care 
facility in each defined substate region[C] that could support initial 
evaluation and treatment of at least 10 patients (adult and pediatric) 
at a time in negative pressure isolation within 3 hours of an event. 

Sentinel indicator: Hospital negative pressure isolation: Number of 
participating hospitals statewide that have the capacity to maintain at 
least one suspected highly infectious disease case in negative pressure 
isolation; 
Criteria we used[A]: State reported that all participating hospitals in 
the state were able to maintain at least one suspected highly 
infectious disease case in negative pressure isolation. 

Sentinel indicator: Surge beds: Number of beds statewide, above the 
current daily staffed bed capacity, that the state is capable of 
surging beyond within 24 hours post-event; 
Criteria we used[A]: State reported that within 24 hours of a mass 
casualty event, its hospitals would be able to add enough additional 
hospital beds to the state's current daily staffed bed capacity to 
provide triage treatment and initial stabilization for an additional 
500 patients per million population. 

Sentinel indicator: Pharmaceutical caches: 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; 
Criteria we used[A]: State reported that all its 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 its 
facilities for a 72-hour period.[D]. 

Source: GAO analysis of recipient-reported data, the Health Resources 
and Services Administration's (HRSA) 2005 National Bioterrorism 
Hospital Preparedness Program guidance, and DHS's Target Capability 
List. 

Note: Prior to March 2007, the Hospital Preparedness Program was 
administered by HHS's HRSA and was named the National Bioterrorism 
Hospital Preparedness Program. 

[A] Because ASPR's guidance for the 2006 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 five of the indicators related to 
hospital capacity from either ASPR's previous program guidance or DHS's 
Target Capabilities List. 

[B] Negative pressure isolation rooms maintain a flow of air into the 
room to ensure that contaminants and pathogens cannot escape from the 
room to other parts of the facility and to protect the health of 
workers and other patients. 

[C] Each recipient was required to subdivide its state into regions. 

[D] Officials from one state said they did not know how to determine 
whether their hospitals had access to caches that were "sufficient." 

[End of table] 

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.[Footnote 31] 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.[Footnote 32] 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.[Footnote 33] 

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.[Footnote 34] 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. 
[Footnote 35] 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.[Footnote 36] 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. 

Eighteen States Were Selecting Alternate Care Sites: 

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.[Footnote 37] 

Fifteen States Had Begun Registering Volunteers in Electronic Medical 
Volunteer Registries: 

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.[Footnote 38] 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. 

Seven of the 20 States Were Planning for Altered Standards of Medical 
Care: 

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.[Footnote 39] 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[Footnote 40] when planning for 
altered standards of care. 

States Reported Concerns Related to All Four Key Components When 
Preparing for Medical Surge: 

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. 

Hospital Capacity Concerns: 

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, 
[Footnote 41] 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. 

Alternate Care Site Concerns: 

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. 
[Footnote 42] 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.[Footnote 43] 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)[Footnote 44] and the Emergency 
Medical Treatment and Labor Act (EMTALA)[Footnote 45]--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.[Footnote 46] 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.[Footnote 47] 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.[Footnote 48] 

Electronic Medical Volunteer Registry Concerns: 

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)[Footnote 49] 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),[Footnote 50] and the American 
Red Cross. This may cause staffing problems in the event of an 
emergency when more than one volunteer program is activated. 

Altered Standards of Care Concerns: 

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, 
[Footnote 51] which would exceed the current capacity of U.S. hospitals 
and necessitate difficult choices regarding rationing of resources. 
[Footnote 52] 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.[Footnote 53] 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,[Footnote 54] 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. 

Other Programmatic and Regulatory Concerns: 

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. 

Conclusions: 

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. 

Recommendation for Executive Action: 

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. 

Agency Comments and Our Evaluation: 

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 [hyperlink, 
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. 

Signed by: 

Cynthia A. Bascetta: 
Director, Health Care: 

List of Requesters: 

The Honorable Judd Gregg: 
Ranking Member: 
Committee on the Budget: 
United States Senate: 

The Honorable Charles E. Grassley: 
Ranking Member: 
Committee on Finance: 
United States Senate: 

The Honorable Bennie G. Thompson: 
Chairman: 
Committee on Homeland Security: 
House of Representatives: 

The Honorable Henry A. Waxman: 
Chairman: 
Committee on Oversight and Government Reform: 
House of Representatives: 

The Honorable Edward J. Markey: 
House of Representatives: 

[End of section] 

Appendix I: Fifteen Hospital Preparedness Program 2006 Sentinel 
Indicators: 

Table 2: 

Sentinel indicator[A]: 1. 
The number of hospitals statewide. 

Sentinel indicator[A]: 2. 
Total number of participating hospitals statewide. 

Sentinel indicator[A]: 3. 
Total population statewide. 

Sentinel indicator[A]: 4. 
Number of beds statewide, above the current daily staffed bed 
capacity, that awardee is capable of surging beyond within 24 hours 
post-event. 

Sentinel indicator[A]: 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. 

Sentinel indicator[A]: 6. 
Number of participating hospitals statewide that have the capacity to 
maintain at least one suspected highly infectious disease case in 
negative pressure isolation. 

Sentinel indicator[A]: 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. 

Sentinel indicator[A]: 8. 
Number of ambulatory and nonambulatory persons that can be 
decontaminated within a 3-hour period, statewide. 

Sentinel indicator[A]: 9. 
Number of health care personnel, statewide, trained through competency-
based programs. 

Sentinel indicator[A]: 10. 
Number of hospital lab personnel, statewide, trained in the protocols 
for referral of clinical samples and associated information. 

Sentinel indicator[A]: 11. 
Functional state-based ESAR-VHP[B] system in place that allows 
qualified, competent volunteer health care professionals to register 
for work in hospitals or other facilities during an emergency 
situation. 

Sentinel indicator[A]: 12. 
Number of volunteer health professionals by discipline and 
credentialing level currently registered in the state-based ESAR-VHP[B] 
system. 

Sentinel indicator[A]: 13. 
Number of drills conducted during the fiscal year 2006 budget period 
that included hospital personnel, equipment, or facilities. 

Sentinel indicator[A]: 14. 
Number of tabletop exercises conducted during the fiscal year 2006 
budget period that included hospital personnel, equipment, or 
facilities. 

Sentinel indicator[A]: 15. 
Number of functional exercises conducted during the fiscal year 2006 
budget period that included hospital personnel, equipment, or 
facilities. 

Source: Office of the Assistant Secretary for Preparedness and Response 
(ASPR). 

[A] The five sentinel indicators that were analyzed in this report for 
hospital capacity are 2, 4, 5, 6, and 7. 

[B] ESAR-VHP is the Emergency System for Advance Registration of 
Volunteer Health Professionals. 

[End of table] 

[End of section] 

Appendix II: Scope and Methodology: 

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,[Footnote 55] 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.[Footnote 56] 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[Footnote 57]--at the time of our data collection) 
for the 50 states.[Footnote 58] We also reviewed the 15 sentinel 
indicators for the Hospital Preparedness Program.[Footnote 59] 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.[Footnote 60] 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. 
[Footnote 61] 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. 

[End of section] 

Appendix III: Hospital Preparedness Program Funding and Medical Surge 
Guidance and Conferences: 

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. 

Table 3: ASPR's Hospital Preparedness Program Funding by State, Fiscal 
Years 2002 through 2007: 

State: Alabama; 
FY 2002: $1,972,833; 
FY 2003: $7,762,315; 
FY 2004: $7,762,315; 
FY 2005: $7,326,068; 
FY 2006: $7,154,927; 
FY 2007[A]: $6,330,289. 

State: Alaska; 
FY 2002: $492,877; 
FY 2003: $1,958,803; 
FY 2004: $1,958,803; 
FY 2005: $1,484,009; 
FY 2006: $1,458,182; 
FY 2007[A]: $1,349,441. 

State: Arizona; 
FY 2002: $2,237,637; 
FY 2003: $9,030,450; 
FY 2004: $9,030,450; 
FY 2005: $8,964,023; 
FY 2006: $8,753,827; 
FY 2007[A]: $8,317,173. 

State: Arkansas; 
FY 2002: $1,285,691; 
FY 2003: $5,077,591; 
FY 2004: $5,077,591; 
FY 2005: $4,633,962; 
FY 2006: $4,531,309; 
FY 2007[A]: $4,063,403. 

State: California; 
FY 2002: $9,962,905; 
FY 2003: $38,773,726; 
FY 2004: $38,773,727; 
FY 2005: $39,203,268; 
FY 2006: $38,325,286; 
FY 2007[A]: $34,106,620. 

State: Colorado; 
FY 2002: $1,916,334; 
FY 2003: $7,704,930; 
FY 2004: $7,704,930; 
FY 2005: $7,401,669; 
FY 2006: $7,221,888; 
FY 2007[A]: $6,525,958. 

State: Connecticut; 
FY 2002: $1,569,336; 
FY 2003: $6,197,207; 
FY 2004: $6,197,207; 
FY 2005: $5,783,087; 
FY 2006: $5,651,890; 
FY 2007[A]: $4,943,121. 

State: Delaware; 
FY 2002: $553,571; 
FY 2003: $2,205,406; 
FY 2004: $2,205,406; 
FY 2005: $1,739,851; 
FY 2006: $1,709,476; 
FY 2007[A]: $1,581,970. 

State: Florida; 
FY 2002: $6,441,669; 
FY 2003: $25,775,967; 
FY 2004: $25,775,967; 
FY 2005: $26,311,287; 
FY 2006: $25,638,227; 
FY 2007[A]: $23,432,938. 

State: Georgia; 
FY 2002: $3,421,481; 
FY 2003: $13,719,390; 
FY 2004: $13,719,390; 
FY 2005: $13,671,367; 
FY 2006: $13,330,420; 
FY 2007[A]: $12,370,869. 

State: Hawaii; 
FY 2002: $719,356; 
FY 2003: $2,856,721; 
FY 2004: $2,856,721; 
FY 2005: $2,407,137; 
FY 2006: $2,345,600; 
FY 2007[A]: $2,129,653. 

State: Idaho; 
FY 2002: $751,285; 
FY 2003: $2,998,297; 
FY 2004: $2,998,297; 
FY 2005: $2,572,244; 
FY 2006: $2,521,506; 
FY 2007[A]: $2,359,069. 

State: Illinois; 
FY 2002: $3,939,374; 
FY 2003: $15,875,995; 
FY 2004: $15,875,995; 
FY 2005: $15,578,388; 
FY 2006: $14,951,481; 
FY 2007[A]: $13,163,842. 

State: Indiana; 
FY 2002: $2,605,616; 
FY 2003: $10,270,929; 
FY 2004: $10,270,929; 
FY 2005: $9,896,622; 
FY 2006: $9,660,723; 
FY 2007[A]: $8,503,785. 

State: Iowa; 
FY 2002: $1,383,675; 
FY 2003: $5,436,624; 
FY 2004: $5,436,624; 
FY 2005: $4,965,024; 
FY 2006: $4,846,845; 
FY 2007[A]: $4,280,453. 

State: Kansas; 
FY 2002: $1,291,509; 
FY 2003: $5,088,830; 
FY 2004: $5,088,830; 
FY 2005: $4,630,597; 
FY 2006: $4,525,854; 
FY 2007[A]: $4,004,077. 

State: Kentucky; 
FY 2002: $1,815,805; 
FY 2003: $7,156,894; 
FY 2004: $7,156,894; 
FY 2005: $6,745,252; 
FY 2006: $6,585,429; 
FY 2007[A]: $5,832,130. 

State: Louisiana; 
FY 2002: $1,981,308;
FY 2003: $7,764,518; 
FY 2004: $7,764,518; 
FY 2005: $7,319,242; 
FY 2006: $7,139,266; 
FY 2007[A]: $5,935,695. 

State: Maine;
FY 2002: $743,913; 
FY 2003: $2,943,648; 
FY 2004: $2,943,648; 
FY 2005: $2,480,391; 
FY 2006: $2,434,432; 
FY 2007[A]: $2,175,388. 

State: Maryland; 
FY 2002: $2,301,890; 
FY 2003: $9,150,163; 
FY 2004: $9,150,163; 
FY 2005: $8,855,085; 
FY 2006: $8,645,984; 
FY 2007[A]: $7,619,177. 

State: Massachusetts; 
FY 2002: $2,709,678; 
FY 2003: $10,686,180; 
FY 2004: $10,686,180; 
FY 2005: $10,256,868; 
FY 2006: $9,983,770; 
FY 2007[A]: $8,660,567. 

State: Michigan; 
FY 2002: $4,100,212; 
FY 2003: $16,141,386; 
FY 2004: $16,141,386; 
FY 2005: $15,787,720; 
FY 2006: $15,395,465; 
FY 2007[A]: $13,298,463. 

State: Minnesota; 
FY 2002: $2,155,835; 
FY 2003: $8,542,551; 
FY 2004: $8,542,551; 
FY 2005: $8,173,336; 
FY 2006: $7,983,328; 
FY 2007[A]: $7,050,445. 

State: Mississippi; 
FY 2002: $1,352,037; 
FY 2003: $5,327,321; 
FY 2004: $5,327,321; 
FY 2005: $4,869,883; 
FY 2006: $4,759,591; 
FY 2007[A]: $4,189,754. 

State: Missouri; 
FY 2002: $2,417,618; 
FY 2003: $9,530,322; 
FY 2004: $9,530,322; 
FY 2005: $9,151,953; 
FY 2006: $8,951,388; 
FY 2007[A]: $7,906,932. 

State: Montana; 
FY 2002: $599,516; 
FY 2003: $,370,015; 
FY 2004: $2,370,015; 
FY 2005: $1,891,709; 
FY 2006: $1,856,928; 
FY 2007[A]: $1,697,530. 

State: Nebraska; 
FY 2002: $912,954; 
FY 2003: $3,602,747; 
FY 2004: $3,602,747; 
FY 2005: $3,137,831; 
FY 2006: $3,067,393; 
FY 2007[A]: $2,741,751. 

State: Nevada; 
FY 2002: $1,024,136; 
FY 2003: $4,174,253; 
FY 2004: $4,174,253; 
FY 2005: $3,899,038; 
FY 2006: $3,818,014; 
FY 2007[A]: $3,663,636. 

State: New Hampshire; 
FY 2002: $728,751; 
FY 2003: $2,905,650; 
FY 2004: $2,905,650; 
FY 2005: $2,452,975; 
FY 2006: $2,404,444; 
FY 2007[A]: $2,166,921. 

State: New Jersey; 
FY 2002: $3,509,769; 
FY 2003: $13,878,940; 
FY 2004: $13,878,940; 
FY 2005: $13,601,391; 
FY 2006: $13,269,518; 
FY 2007[A]: $11,560,312. 

State: New Mexico; 
FY 2002: $354,709; 
FY 2003: $3,770,553; 
FY 2004: $3,770,553; 
FY 2005: $3,343,195; 
FY 2006: $3,276,757; 
FY 2007[A]: $2,977,887. 

State: New York; 
FY 2002: $4,499,138; 
FY 2003: $18,019,873; 
FY 2004: $18,019,873; 
FY 2005: $17,757,875; 
FY 2006: $16,937,704; 
FY 2007[A]: $14,561,258. 

State: North Carolina; 
FY 2002: $3,368,351; 
FY 2003: $13,417,400; 
FY 2004: $13,417,400; 
FY 2005: $13,251,044; 
FY 2006: $12,948,887; 
FY 2007[A]: $11,727,581. 

State: North Dakota; 
FY 2002: 498,792; 
FY 2003: $1,963,221; 
FY 2004: $1,963,221; 
FY 2005: $1,461,290; 
FY 2006: $1,435,800; 
FY 2007[A]: $1,306,102. 

State: Ohio; 
FY 2002: $4,648,274; 
FY 2003: $18,234,914; 
FY 2004: $18,234,914; 
FY 2005: $17,843,984; 
FY 2006: $17,397,207; 
FY 2007[A]: $15,050,914. 

State: Oklahoma; 
FY 2002: $1,586,804; 
FY 2003: $6,250,131; 
FY 2004: $6,250,131; 
FY 2005: $5,825,603; 
FY 2006: $5,681,308; 
FY 2007[A]: $5,037,444. 

State: Oregon; 
FY 2002: $1,575,470; 
FY 2003: $6,255,978; 
FY 2004: $6,255,978; 
FY 2005: $5,898,716; 
FY 2006: $5,767,951; 
FY 2007[A]: $5,191,530. 

State: Pennsylvania; 
FY 2002: $5,007,754; 
FY 2003: $19,616,940; 
FY 2004: $19,616,940; 
FY 2005: $19,254,011; 
FY 2006: $18,776,677; 
FY 2007[A]: $16,271,242. 

State: Rhode Island; 
FY 2002: $656,125; 
FY 2003: $2,603,466; 
FY 2004: $2,603,466; 
FY 2005: $2,132,147; 
FY 2006: $2,089,651; 
FY 2007[A]: $1,853,432. 

State: South Carolina; 
FY 2002: $1,804,277; 
FY 2003: $7,146,769; 
FY 2004: $7,146,769; 
FY 2005: $6,789,755; 
FY 2006: $6,632,258; 
FY 2007[A]: $5,978,140. 

State: South Dakota; 
FY 2002: $542,431; 
FY 2003: $2,147,489; 
FY 2004: $2,147,489; 
FY 2005: $1,659,192; 
FY 2006: $1,630,322; 
FY 2007[A]: $1,491,255. 

State: Tennessee; 
FY 2002: $2,454,062; 
FY 2003: $9,699,934; 
FY 2004: $9,699,934; 
FY 2005: $9,359,882; 
FY 2006: $9,138,647; 
FY 2007[A]: $8,155,520. 

State: Texas; 
FY 2002: $8,328,119; 
FY 2003: $33,338,368; 
FY 2004: $33,338,368; 
FY 2005: $34,045,388; 
FY 2006: $33,177,278; 
FY 2007[A]: $30,301,320. 

State: Utah; 
FY 2002: $1,115,143; 
FY 2003: $4,448,125; 
FY 2004: $4,448,125; 
FY 2005: $4,066,334; 
FY 2006: $3,978,558; 
FY 2007[A]: $3,732,769. 

State: Vermont; 
FY 2002: $485,864; 
FY 2003: $1,927,552; 
FY 2004: $1,927,552; 
FY 2005: $1,438,965; 
FY 2006: $1,415,048; 
FY 2007[A]: $1,290,942. 

State: Virginia; 
FY 2002: $2,992,259; 
FY 2003: v11,890,053; 
FY 2004: $11,890,053; 
FY 2005: $11,701,905; 
FY 2006: $11,387,068; 
FY 2007[A]: $10,189,048. 

State: Washington; 
FY 2002: $2,533,418; 
FY 2003: $10,069,141; 
FY 2004: $10,069,141; 
FY 2005: $9,799,166; 
FY 2006: $9,562,647; 
FY 2007[A]: $8,608,090. 

State: West Virginia; 
FY 2002: $950,564; 
FY 2003: $3,725,218; 
FY 2004: $3,725,218; 
FY 2005: $3,245,672; 
FY 2006: $3,176,132; 
FY 2007[A]: $2,805,313. 

State: Wisconsin; 
FY 2002: $2,327,920; 
FY 2003: $9,180,227; 
FY 2004: $9,180,227; 
FY 2005: $8,799,529; 
FY 2006: $8,588,953; 
FY 2007[A]: $7,544,102. 

State: Wyoming; 
FY 2002: $441,296; 
FY 2003: $1,747,144; 
FY 2004: $1,747,144; 
FY 2005: $1,260,221; 
FY 2006: $1,241,982; 
FY 2007[A]: $1,152,882. 

State: Total; 
FY 2002: $113,669,341; 
FY 2003: $450,360,266; 
FY 2004: $450,360,266; 
FY 2005: $434,115,151; 
FY 2006: $423,163,319; 
FY 2007[A]: $377,188,133. 

Source: ASPR. 

[A] The fiscal year 2007 funds for the Hospital Preparedness Program 
were awarded to the states in September 2007. States can expend these 
funds during the 2007 program year, which runs from September 1, 2007, 
to August 8, 2008. 

[End of table] 

Table 4: Federal Guidance and Technical Assistance Published for States 
to Use in Preparing for Medical Surge: 

Federal guidance: 
* National Response Framework; 
* Target Capabilities List; 
* Homeland Security Presidential Directive 10 (HSPD-10) Biodefense for 
the 21st Century; 
* Homeland Security Presidential Directive 21 (HSPD-21) Public Health 
and Medical Preparedness. 

HHS planning guidance: 
* State & Local Pandemic Influenza Planning Checklist; 
* Law Enforcement Pandemic Influenza Planning Checklist; 
* Correctional Facilities Pandemic Influenza Planning Checklist; 
* Draft Guidance on Allocating and Targeting Pandemic Influenza 
Vaccine; 
* Interim Public Health Guidance for the Use of Facemasks and 
Respirators in Non-Occupational Community Settings during an Influenza 
Pandemic (CDC); 
* [hyperlink, http://www.Pandemicflu.gov]; 
* In a Moment's Notice: Surge Capacity for Terrorist Bombings (CDC). 

ASPR programs: 
* Hospital Preparedness Program; 
* Healthcare Facilities Partnership Program; 
* Healthcare Facilities Emergency Care Partnership Program; 
* Emergency System for Advance Registration of Volunteer Health 
Professionals (ESAR-VHP) Program; 
* Bioterrorism Training Curriculum Development Program; 
* Regional Emergency Coordinators. 

SPR planning documents and handbooks: 
* HHS Plan to Combat Bioterrorism and Other Public Health Emergencies; 
* Medical Surge Capacity and Capability Handbook; 
* Emergency Management Assistance Compact Quick Tips; 
* Interim Public Health and Healthcare Supplement to the National 
Preparedness Goal. 

AHRQ tools and resources: 
* Adapting Community Call Centers for Crisis Support[A]; 
* Altered Standards of Care in Mass Casualty Events[A]; 
* Bioterrorism and Emerging Infections Site; 
* CBRNE (Chemical, Biological, Radiological, Nuclear, and Explosive) 
Events (Questionnaire); 
* Community-Based Mass Prophylaxis: A Planning Guide for Public Health 
Preparedness; 
* Computer Staffing Model for Bioterrorism Response-- BERM Version 2; 
* Decontamination of Children: Preparedness and Response for Hospital 
Emergency Departments: Video; 
* Emergency Preparedness Atlas: U.S. Nursing Home and Hospital 
Facilities[A]; 
* Emergency Preparedness Resource Inventory (EPRI); 
* Emergency Severity Index; 
* Evaluation of Hospital Disaster Drills: A Module-Based Approach; 
* Health Emergency Assistance Line and Triage Hub (HEALTH) Model; 
* Nursing Homes in Public Health Emergencies[A]; 
* Pediatric Terrorism and Disaster Preparedness: A Resource for 
Pediatricians; 
* Personal Protective Equipment, Decontamination, Isolation/Quarantine, 
and Laboratory Capacity; 
* Predicting Health Care Use Resulting From Terrorism: Tools To Aid 
State Planning: Summary; 
* Mass Medical Care with Scarce Resources: A Community Planning 
Guide[A]; 
* National Hospital Available Beds for Emergencies and Disasters 
(HAvBED) System: Final Report and Appendixes[A]; 
* Project XTREME: Cross-Training Respiratory Extenders for Medical 
Emergencies[A]; 
* Readiness and Response to Public Health Emergencies: Help Needed Now 
From Professional Nursing Associations; 
* Reopening Shuttered Hospitals to Expand Surge Capacity (Surge Toolkit 
and Facility Checklist)[A]; 
* Rocky Mountain Regional Care Model for Bioterrorist Events (Alternate 
Care Site Selection Tool)[A]; 
* Standardized Hospital Bed Definitions (HAvBED); 
* Understanding Needs for Health System Preparedness and Capacity for 
Bioterrorist Attacks (Questionnaire); 

AHRQ issue briefs: 
* Addressing the Smallpox Threat: Issues, Strategies, and Tools; 
* Disaster Planning Drills and Readiness Assessment; 
* Optimizing Surge Capacity: Hospital Assessment and Planning; 
* Optimizing Surge Capacity: Regional Efforts in Bioterrorism 
Readiness; 
* The Role of Information Technology and Surveillance Systems in 
Bioterrorism Readiness; 
* Bioterrorism and Other Public Health Emergencies: Linkages with 
Community Providers; 
* Surge Capacity--Education and Training for a Qualified Workforce; 
* Surge Capacity: Facilities and Equipment; 
* Addressing Surge Capacity in a Mass Casualty Event; 
* Mass Prophylaxis: Building Blocks for Community Preparedness; 
* Developing Alternative Approaches to Mass Casualty Care. 

AHRQ evidence reports: 
* Evidence Report/Technology Assessment: Number 51: Training of 
Clinicians for Public Health Events Relevant to Bioterrorism 
Preparedness; 
* Evidence Report/Technology Assessment: Number 59: Bioterrorism 
Preparedness and Response: Use of Information Technologies and Decision 
Support Systems; 
* Evidence Report/Technology Assessment: Number 95: Training of 
Hospital Staff To Respond to a Mass Casualty Incident; 
* Evidence Report/Technology Assessment: Number 96: Regionalization of 
Bioterrorism Preparedness and Response; 
* Evidence Report/Technology Assessment: Number 141: Pediatric Anthrax: 
Implications for Bioterrorism Preparedness. 

RAND reports and tools: 
* Improving and Enhancing Telephone-based Disease Surveillance Systems 
in Local Health Departments[B]; 
* Assessing Public Health Emergency Preparedness: Concepts, Tools, and 
Challenges; 
* Enhancing Public Health Preparedness: Exercises, Exemplary Practices, 
and Lessons Learned, Phase III[B]; 
* Quality Improvement - Implications for Public Health Preparedness[B]; 
* Public Health Preparedness - Integrating Public Health and Hospital 
Preparedness[B]; 
* Organizing State and Local Health Departments for Public Health 
Preparedness[B]; 
* Tabletop Exercises for Pandemic Influenza Preparedness in Local 
Public Health Agencies[B]; 
* Facilitated Look Backs - A New Quality Improvement Tool for 
Management of Routine Annual and Pandemic Influenza[B]; 
* Enhancing Public Health Preparedness: Exercises, Exemplary Practices, 
and Lessons Learned[B]; 
* Exemplary Practices in Public Health Preparedness[B]; 
* Learning From Experience: The Public Health Response to West Nile 
Virus, SARS, Monkeypox, and Hepatitis A Outbreaks in the United 
States[B]; 
* Test to Evaluate Public Health Disease Reporting Systems in Local 
Public Health Agencies[B]; 
* Bioterrorism Preparedness Training and Assessment Exercises for Local 
Public Health Agencies[B]; 
* Tabletop Exercise for Pandemic Influenza Preparedness in Local Public 
Health Agencies[B]; 
* Quality Improvement: Implications for Public Health Preparedness[B]; 
* Designing and Conducting Tabletop Exercises to Assess Public Health 
Preparedness for Manmade and Naturally Occurring Biological Threats. 

National Highway Traffic Safety Administration resources: 
*EMS Pandemic Influenza Guidelines for Statewide Adoption; 
* Recommendations for Protocol Development for 9-1-1 Personnel. 

Source: HHS. 

[A] Projects for which ASPR awarded funding and provided support and 
direction. 

[B] HHS contracted with RAND to produce these reports and tools. 

[End of table] 

Table 5: Federal Conferences and Meetings with States That Provided 
Information to Prepare for Medical Surge: 

HHS conference: 
* Pandemic Planning: A Convening of the States, December 5, 2005. 

ASPR conferences: 
* Annual Hospital Preparedness Program Cooperative Agreement Recipient 
Conference; 
* Annual ESAR-VHP Conference; 
* 2008 Bioterrorism Training and Curriculum Development Program 
Conference. 

AHRQ conferences: 
* Public Health Emergencies: Strategies and Tools for Meeting the Needs 
of Children, Web Conference, January 11, 2006; 
* Mass Casualty Care: Overlooked Community Resources, Web Conference, 
May 17, 2005; 
* Addressing Surge Capacity in a Mass Casualty Event, Web Conference, 
October 26, 2004; 
* Surge Capacity and Health System Preparedness: Facilities and 
Equipment, Web Conference, July 13, 2004; 
* Surge Capacity and Health System Preparedness: Education and Training 
for a Qualified Workforce, Web Conference, March 2, 2004; 
* Bioterrorism and Other Public Health Emergencies-- Linkages with 
Community Providers, Web Conference, December 16, 2003; 
* The Role of Information/Communication Technology and 
Monitoring/Surveillance Systems in Bioterrorism Preparedness, Web 
Conference, October 21, 2003; 
* Surge Capacity Assessments and Regionalization Issues, Web 
Conference, June 17, 2003; 
* Disaster Planning Drills and Readiness Assessment, Web Conference, 
April 15, 2003; 
* Addressing the Smallpox Threat: Issues, Strategies, and Tools, Web 
Conference, March 3, 2003; 
* Bioterrorism and Health System Preparedness, Web Conference, April 
29, 30, and May 1, 2002; 
* Expert Meeting on Bioterrorism, February 18, 2000. 

Source: HHS. 

[End of table] 

[End of section] 

Appendix IV: Data for the Five Surge-Related Sentinel Indicators for 
Hospital Capacity from the Hospital Preparedness Program: 

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. 

Figure 1: Hospital Participation in Individual States' Hospital 
Preparedness Programs: 

[See PDF for image] 

This figure is a vertical bar graph depicting the following data: 

Percentage of hospitals participating in program: 0-9%; 
Number of states: 0; 

Percentage of hospitals participating in program: 10-19%; 
Number of states: 0. 

Percentage of hospitals participating in program: 20-29%; 
Number of states: 0. 

Percentage of hospitals participating in program: 30-39%; 
Number of states: 0. 

Percentage of hospitals participating in program: 40-49%; 
Number of states: 1. 

Percentage of hospitals participating in program: 50-59%; 
Number of states: 0. 

Percentage of hospitals participating in program: 60-69%; 
Number of states: 3. 

Percentage of hospitals participating in program: 70-79%; 
Number of states: 2. 

Percentage of hospitals participating in program: 80-89%; 
Number of states: 6. 

Percentage of hospitals participating in program: 90-100%; 
Number of states: 38. 

Source: GAO analysis of ASPR data. 

[End of figure] 

Figure 2: States Whose Regions Have the Capability to Treat at Least 10 
Patients at a Time in Negative Pressure Isolation: 

[See PDF for image] 

This figure is a vertical bar graph depicting the following data: 

Percentage of regions with the capability to treat at least 10 patients 
at a time in negative pressure isolation: 0-9%; 
Number of states: 0; 

Percentage of regions with the capability to treat at least 10 patients 
at a time in negative pressure isolation: 10-19%; 
Number of states: 0. 

Percentage of regions with the capability to treat at least 10 patients 
at a time in negative pressure isolation: 20-29%; 
Number of states: 0. 

Percentage of regions with the capability to treat at least 10 patients 
at a time in negative pressure isolation: 30-39%; 
Number of states: 0. 

Percentage of regions with the capability to treat at least 10 patients 
at a time in negative pressure isolation: 40-49%; 
Number of states: 0. 

Percentage of regions with the capability to treat at least 10 patients 
at a time in negative pressure isolation: 50-59%; 
Number of states: 1. 

Percentage of regions with the capability to treat at least 10 patients 
at a time in negative pressure isolation: 60-69%; 
Number of states: 0. 

Percentage of regions with the capability to treat at least 10 patients 
at a time in negative pressure isolation: 70-79%; 
Number of states: 3. 

Percentage of regions with the capability to treat at least 10 patients 
at a time in negative pressure isolation: 80-89%; 
Number of states: 3. 

Percentage of regions with the capability to treat at least 10 patients 
at a time in negative pressure isolation: 90-100%; 
Number of states: 43. 

Source: GAO analysis of ASPR data. 

[End of figure] 

Figure 3: States with Participating Hospitals That Have Negative 
Pressure Isolation Capabilities: 

[See PDF for image] 

This figure is a vertical bar graph depicting the following data: 

Percentage of participating hospitals with negative pressure isolation 
capabilities: 0-9%; 
Number of states: 0; 

Percentage of participating hospitals with negative pressure isolation 
capabilities: 10-19%; 
Number of states: 0. 

Percentage of participating hospitals with negative pressure isolation 
capabilities: 20-29%; 
Number of states: 0. 

Percentage of participating hospitals with negative pressure isolation 
capabilities: 30-39%; 
Number of states: 0. 

Percentage of participating hospitals with negative pressure isolation 
capabilities: 40-49%; 
Number of states: 0. 

Percentage of participating hospitals with negative pressure isolation 
capabilities: 50-59%; 
Number of states: 2. 

Percentage of participating hospitals with negative pressure isolation 
capabilities: 60-69%; 
Number of states: 3. 

Percentage of participating hospitals with negative pressure isolation 
capabilities: 70-79%; 
Number of states: 1. 

Percentage of participating hospitals with negative pressure isolation 
capabilities: 80-89%; 
Number of states: 2. 

Percentage of participating hospitals with negative pressure isolation 
capabilities: 90-100%; 
Number of states: 42. 

Source: GAO analysis of ASPR data. 

[End of figure] 

Figure 4: Number of Additional Surge Beds per Million Population That 
Can Be Added above Normal Capacity within 24 Hours: 

[See PDF for image] 

This figure is a vertical bar graph depicting the following data: 

Number of surge beds per million population that can be added above 
normal capacity within 24 hours: 0-99; 
Number of states: 0. 

Number of surge beds per million population that can be added above 
normal capacity within 24 hours: 100-199; 
Number of states: 1. 

Number of surge beds per million population that can be added above 
normal capacity within 24 hours: 200-299; 
Number of states: 3. 

Number of surge beds per million population that can be added above 
normal capacity within 24 hours: 300-399; 
Number of states: 4. 

Number of surge beds per million population that can be added above 
normal capacity within 24 hours: 400-499; 
Number of states: 4. 

Number of surge beds per million population that can be added above 
normal capacity within 24 hours: 500+; 
Number of states: 37. 

Note: One state reported that it did not know the number of surge beds 
that could be added. 

Source: GAO analysis of ASPR data. 

[End of figure] 

Figure 5: States Whose Participating Hospitals Have Sufficient 
Pharmaceuticals to Treat Hospital Personnel and Their Family Members: 

[See PDF for image] 

This figure is a vertical bar graph depicting the following data: 

Percentage of participating hospitals with sufficient caches: 0-9%; 
Number of states: 4; 

Percentage of participating hospitals with sufficient caches: 10-19%; 
Number of states: 2. 

Percentage of participating hospitals with sufficient caches: 20-29%; 
Number of states: 5. 

Percentage of participating hospitals with sufficient caches: 30-39%; 
Number of states: 4. 

Percentage of participating hospitals with sufficient caches: 40-49%; 
Number of states: 3. 

Percentage of participating hospitals with sufficient caches: 50-59%; 
Number of states: 1. 

Percentage of participating hospitals with sufficient caches: 60-69%; 
Number of states: 1. 

Percentage of participating hospitals with sufficient caches: 70-79%; 
Number of states: 1. 

Percentage of participating hospitals with sufficient caches: 80-89%; 
Number of states: 2. 

Percentage of participating hospitals with sufficient caches: 90-100%; 
Number of states: 26. 

Source: GAO analysis of ASPR data. 

Note: One state reported that it did not know the number of sufficient 
pharmaceutical caches that were available because it was unsure of the 
definition of "sufficient." 

[End of figure] 

[End of section] 

Appendix V: Comments from the Department of Health and Human Services: 

The Secretary Of Health And Human Services: 
Washington, DC 20201: 

May 23, 2008: 

Cynthia A. Bascetta: 
Director, Health Care: 
U.S. Government Accountability Office: 
Washington, DC 20548: 

Dear Ms. Bascetta: 

Enclosed are the Department's comments on the U.S. Government 
Accountability Office's (GAO) draft report entitled, "Emergency 
Preparedness: States are Planning for Medical Surge, but Could Benefit 
from Shared Guidance for Allocating Scarce Medical Resources" (GAO-08-
668). 

The Department appreciates the opportunity to review and comment on 
this draft before its publication. 

Sincerely, 

Signed by: 
Jennifer R. Luong, for: 
Vincent J. Ventimiglia, Jr. 
Assistant Secretary for Legislation: 

Attachment: 

Comments Of The Department Of Health And Human Services (HHS) On The 
Government Accountability Office's (GAO) Draft Report Entitled: 
"Emergency Preparedness: States Are Planning For Medical Surge, But 
Could Benefit From Shared Guidance For Allocating Scarce Medical 
Resources" (GAO-08-668): 

Overall, the report is a fair representation of progress that has been 
made to improve medical surge capacity since 2001. This report focuses 
on the activities and concerns of State agencies and officials. Since 
"all disasters are local", it might be more worthwhile to have some 
local perspectives included as well. 

The program name for ESAR-VHP is incorrect throughout the report. The 
program name is the "Emergency System for Advance Registration of 
Volunteer Health Professionals". "Systems" should be changed to 
"System" in each occurrence. 

[End of section] 

Appendix VI: Comments from the Department of Homeland Security: 

U.S. Department of Homeland Security: 
Washington, DC 20528: 

May 16, 2008: 

Ms. Cynthia Bascetta: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G St. NW: 
Washington, D.C. 20548: 

Dear Ms. Bascetta: 

Thank you for the opportunity to review and provide comments on the 
Government Accountability Office's (GAO) draft report entitled, 
Emergency Preparedness: States Are Planning for Medical Surge, but 
Could Benefit from Shared Guidance for Allocating Scarce Medical 
Resources (GAO-08-668). 

The Department of Homeland Security (DHS) has reviewed the referenced 
GAO Report, and we concur with the findings. We would like to offer a 
comment on the issue of altered standards of care. GAO offers a 
definition of "standard of care" in footnote number 4 (pg. 2) which we 
feel to be accurate and generally accepted. Our concern is that the 
discussion as written is not one of altered standards of care, but 
rather the public's need to accept an altered expectation of care. If, 
as defined in footnote number 4, a standard of care is "how similarly 
qualified health care providers would manage the patient's care under 
the same or similar circumstances" then the "standard" of care does not 
change, but rather it is the type, or level, of care which is altered. 
While this might be construed as semantics, it highlights the need for 
enhanced pre-event public messaging to prepare the population for a 
different look to health care in a mass casualty incident. 

Another point of concern is in the recommendation that the Department 
of Health and Human Services (HHS) provide best practices, or passive 
guidance to states when considering rationing of scarce resources. Upon 
review, it seems that states are having difficulty in getting past the 
ethical and legal issues surrounding rationing. Further exploration may 
be needed regarding the specific facets of the issue and the possible 
production of guidance to direct states' discussion on rationing of 
scarce resources. 

DHS is dedicated to assisting our state partners in maintaining the 
health and resiliency of the homeland. Thank you for the opportunity to 
review and provide comments on this draft report. 

Sincerely, 

Signed by: 

Penelope G. McCormack: 
Acting Director: 
Departmental GAO/OIG Liaison Office: 

[End of section] 

Appendix VII: Comments from the Department of Defense: 

The Assistant Secretary Of Defense: 
Health Affairs: 
1200 Defense Pentagon: 
Washington, DC 20301-1200: 

May 21, 2008: 

Ms. Cynthia A. Bascetta: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street, N.W. 
Washington, DC 20548: 

Dear Ms. Bascetta: 

This is the Department of Defense response to the Government 
Accountability Office (GAO) draft report, GAO-08-668, "Emergency 
Preparedness: States Are Planning for Medical Surge, but Could Benefit 
from Shared Guidance for Allocating Scarce Medical Resources," dated 
May 1, 2008 (GAO Code 290623). 

Thank you for the opportunity to comment on this important report. I 
concur with the GAO's conclusions and findings. The draft report 
reflects the issues and narrative that my staff exchanged with the 
audit team during the research phase of the audit. 

My points of contact on this matter are Captain D. W. Chen 
(Functional), who can be reached at (703) 845-3376, and Mr. Gunther 
Zimmerman (Audit Liaison), who can be reached at (703) 681-4360. 

Sincerely, 

Signed by: 

Stephen L. Jones, for: 
S. Ward Casscells, MD: 

[End of section] 

Appendix VIII: Comments from the Department of Veterans Affairs: 

The Deputy Secretary Of Veterans Affairs: 
Washington: 

May 19, 2008: 

Ms. Cynthia A. Bascetta: 
Director: 
Health Care: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Ms. Bascetta: 

The Department of Veterans Affairs (VA) has reviewed your draft report, 
Emergency Preparedness: States Are Planning for Medical Surge, but 
Could Benefit from Shared Guidance for Allocating Scarce Medical 
Resources (GAO-08-668) and agrees with your findings as they pertain to 
VA. 

The Veterans Health Administration (VHA) and its medical centers commit 
to providing emergency aid and supplies during mass casualty events to 
the best of their ability. VA medical centers are required to meet 
their primary, Congressionally-mandated, mission of delivery of health 
care to veterans and others during times of emergencies. VA medical 
centers would assess Emergency Support Function (ESF) #8 requests for 
public health and medical emergency aid in the context of that which is 
needed to meet VA's primary functions. In addition to that mandate, VA 
cannot commit in advance to providing emergency aid and supplies due to 
a number of factors: 

1. Not all VA medical centers provide emergency services nor do they 
have the same level of emergency supplies. 

2. VA medical centers vary widely in size and complexities. 
Accordingly, VA's capability to provide emergency care and support 
varies widely. 

3. Requiring all VA medical centers to maintain the same level of 
emergency care and capabilities is impractical and cost prohibitive. 

In addition, all VA medical centers are accredited by The Joint 
Commission (TJC), which includes compliance with Emergency Management 
(EM) standards under the Environment of Care (EOC) umbrella. TJC 
evaluates each facility no less than every 3 years, and EM compliance 
is included. This evaluation is based in part on the VA medical 
center's capability and expectations to provide EM services within its 
community. GAO's findings on pages 19-20, which indicate 
inconsistencies from State to State regarding VA medical centers' 
stance towards treating non-veterans in the event of a medical surge, 
likely stem from VA medical centers' varying capabilities to provide 
emergency medical treatment in any given State. 

The GAO draft report (pages 19-20) indicates that a number of States 
reported that VA facilities were either unwilling to treat nonveteran 
patients or lacked the authority to do so. Footnote 95 addresses this 
misconception by stating that VA is authorized to provide emergency 
care to non-veterans on a humanitarian basis. In addition, however, VA 
has specific statutory authority to provide care and services during 
certain disasters and emergencies. That authority is codified in 
section 1785 of title 38, United States Code. Regulations implementing 
this authority were published in the Federal Register on May 12, 2008, 
(73 Fed. Reg. 26945) and will be codified at 38 C.F.R. § 17.86. 

In addition to specific authorities in title 38, United States Code, VA 
also responds to disasters and emergencies pursuant to the authority in 
the Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 
U.S.C. §§ 5121, et seq. (the Stafford Act). The Stafford Act sets forth 
the Federal government's authority to respond to major disasters and 
emergencies. 

The National Response Framework (NRF) is the Federal-wide document 
describing how the Federal government will assist State and local 
responses in major disasters and emergencies. It provides a process and 
a structure for the systematic and coordinated Federal response. The 
Plan organizes the types of Federal response assistance under Emergency 
Support Functions (ESF). Each ESF groups together, by function, the 
types of direct Federal Assistance that a State is most likely to need 
(e.g., mass care, health and medical services) as well as the kinds of 
support that are necessary to sustain the Federal response (e.g., 
transportation, communications). For each of these support functions, 
the NRF designates a "primary agency" which is responsible for planning 
and coordinating the delivery of the function. In addition, the NRF 
designates "support agencies" for each function. VA has a specific 
support role in ESF #3 (Public Works and Engineering), #5 (Emergency 
Management), #6 (Mass Care, Emergency Assistance, Housing, and Human 
Services), #7 (Logistics Management and Resource Support) and #8 
(Public Health and Medical Services). Under the auspices of the NRF, VA 
may be directed to provide assistance to State and local relief 
efforts. 

VA appreciates the opportunity to comment on your draft report. 

Sincerely yours, 

Signed by: 

Gordon H. Mansfield: 

[End of section] 

Footnotes: 

[1] By health care systems, we mean both public health and medical 
systems, including hospitals. 

[2] A bioterrorism attack is the deliberate release of viruses, 
bacteria, or other germs (agents) used to cause illness or death in 
people, animals, or plants. These agents are typically found in nature, 
but it is possible that they could be changed to increase their ability 
to cause disease, to make them resistant to current medicines, or to 
increase their ability to be spread into the environment. Biological 
agents can be spread through the air, through water, or in food. 

[3] A mass casualty event is a public health or medical emergency that 
could involve thousands, or even tens of thousands, of injured or ill 
victims. 

[4] A standard of care is the diagnostic and treatment process that a 
provider should follow for a certain type of patient or illness, or 
certain clinical circumstances. It is how similarly qualified health 
care providers would manage the patient's care under the same or 
similar circumstances. 

[5] Alternate care sites deliver medical care outside of hospital 
settings for patients who would normally be treated as inpatients. 

[6] The term "altered standards" generally means a shift to providing 
care and allocating scarce equipment, supplies, and personnel in a way 
that saves the largest number of lives, in contrast to the traditional 
focus of treating the sickest or most injured patients first. For 
example, it could mean applying principles of field triage to determine 
who gets what kind of care, changing infection control standards to 
permit group isolation rather than single-person isolation units, 
changing who provides various kinds of care, or changing privacy and 
confidentiality protections temporarily. 

[7] See Pub. L. No. 107-296, 116 Stat. 2135 (2002). 

[8] Pub. L. No. 109-417, §101, 120 Stat. 2831, 2832 (2006) (codified at 
42 U.S.C. § 300hh). 

[9] The National Response Framework details the missions, policies, 
structures, and responsibilities of federal agencies for coordinating 
resource and programmatic support to states, tribes, and other federal 
agencies. 

[10] DOD Directive 3025.1, §§ 4.6.1.2. and 4.5.1 Military Support to 
Civil Authorities (Jan. 15, 1993). 

[11] The Joint Commission is an independent, nonprofit organization 
that evaluates and accredits more than 15,000 U.S. health care 
organizations and programs, including DOD and VA hospitals. 

[12] The 2006 program year for the Hospital Preparedness Program was 
September 1, 2006, to August 31, 2007. The 2007 program year is 
September 1, 2007, to August 8, 2008. 

[13] While the Hospital Preparedness Program awards funds annually to 
62 entities--the 50 states; 4 municipalities, including the District of 
Columbia; 5 U.S. territories; and 3 Freely Associated States of the 
Pacific--we limited our review to the 50 states. 

[14] Sentinel indicators are smaller component tasks of critical 
benchmarks, which measure program capacity-building efforts such as 
purchasing equipment and supplies and acquiring personnel. For example, 
for the benchmark "Surge Capacity; Beds," one of the sentinel 
indicators is the number of additional hospital beds for which a 
recipient could make patient care available within 24 hours. ASPR 
requires that states report on 15 sentinel indicators. 

[15] Two of the 15 indicators--total number of hospitals statewide and 
total population statewide--were used as denominators to analyze the 5 
indicators. 

[16] Before 2008, the Homeland Security Grant Program consisted of five 
programs, including the four mentioned and the Law Enforcement 
Terrorism Prevention Program. In 2008 the Law Enforcement Terrorism 
Prevention Program was rolled into the State Homeland Security Program 
and the Urban Areas Security Initiative. 

[17] Prior to March 2007, the Hospital Preparedness Program was 
administered by HHS's Health Resources and Services Administration 
(HRSA) and was named the National Bioterrorism Hospital Preparedness 
Program. 

[18] The four municipalities are the District of Columbia, New York 
City, Chicago, and Los Angeles County; the five U.S. territories are 
Puerto Rico, American Samoa, Guam, the Northern Marianas Islands, and 
the U.S. Virgin Islands; the three Freely Associated States of the 
Pacific are the Federated States of Micronesia, Marshall Islands, and 
Palau. 

[19] Negative pressure isolation rooms maintain a flow of air into the 
room to ensure that contaminants and pathogens cannot escape from the 
room to other parts of the facility and to protect the health of 
workers and other patients. 

[20] A medical volunteer is a professional who renders aid or performs 
health services voluntarily, without pay or remuneration. 

[21] Credentialing is the process of obtaining, verifying, and 
assessing the qualifications of a health care professional. In an 
emergency, a single set of standards and definitions can be assigned to 
medical volunteers so the volunteers can render services across 
communities and state lines. 

[22] The Joint Commission has standards that require hospitals to 
establish organization-specific staff-to-patient ratios based upon the 
organization's assessment of patient care needs. The assessment usually 
involves consideration of numbers, types, and seriousness of illness of 
various patient groups. 

[23] An additional $218 million was provided to four large 
municipalities, five U.S. territories, and three Freely Associated 
States of the Pacific for a total of approximately $2.5 billion. Over 
the 2-year period, fiscal years 2004 and 2005, HHS also awarded an 
additional $200,000 to 48 states for ESAR-VHP development through this 
program. 

[24] Since January 2006, HHS also had awarded the 62 recipients an 
additional $400 million in two phases and a supplement to prepare for a 
pandemic influenza outbreak. The funds were awarded to accelerate their 
current planning efforts for an influenza pandemic and to exercise 
their plans. These funds included $75 million in August 2007 that could 
be used, in part, to develop pandemic alternate care sites and to 
conduct medical surge exercises. 

[25] For example, one of the activities is to receive and treat surge 
casualties. One of the critical tasks associated with this activity is 
to ensure adequacy of medical equipment and supplies in support of 
immediate medical response operations and for restocking requested 
supplies and equipment. 

[26] ESAR-VHP guidelines assign each volunteer to one of four emergency 
credentialing levels depending on the medical credentials possessed and 
verified. For example, Level 4 is assigned to volunteers who have been 
registered into the system, without having any credentials, such as 
licenses, certifications, and hospital privileges, verified. Level 1 is 
assigned to volunteers whose credentials have been fully verified. 

[27] The number of available beds refers to the number of beds that are 
licensed, physically available, and have staff on hand to attend to the 
patient who occupies the bed. These beds must include supporting space, 
equipment, medical supplies, ancillary and support services, and staff 
to operate under normal circumstances. 

[28] The RAND Corporation is a nonprofit institution that conducts 
research and issues reports on social and economic issues, such as 
education, poverty, crime, and the environment, as well as a range of 
national security issues, including emergency preparedness. 

[29] The 2006 program year was from September 1, 2006, to August 31, 
2007; therefore, information provided in the midyear progress reports 
was reported as of March 2007. 

[30] Four of the states we reviewed provided sentinel indicator 
information as of April 2007, one state as of August 2007, and another 
state as of September 2007. 

[31] Among other standards, HAvBED systems are required to report on 
seven categories of staffed available beds. The seven bed categories 
are intensive care, medical and surgical, burn, pediatric intensive 
care, pediatric, psychiatric, and negative pressure isolation. HAvBED 
systems are also required to report on emergency department diversions, 
decontamination facilities available, and ventilators available. ASPR 
allows each state to use Hospital Preparedness Program funds to develop 
its own bed tracking system as long as the system meets HAvBED 
requirements. 

[32] In addition to hospitals, these facilities could include skilled 
nursing facilities, assisted living facilities, and residential 
treatment facilities. 

[33] ASPR requires all recipients to complete the development of their 
bed tracking system by August 8, 2008. 

[34] Directive 3025.1, Section 4.5.1 authorizes military officials to 
take necessary actions to respond to civilian requests for assistance 
in emergencies, which may include accepting civilian patients. This 
decision can be authorized by DOD or, in cases of urgent need, by the 
commander of the local military hospital. 

[35] VA is authorized to furnish hospital care or medical services as a 
humanitarian service to non-VA beneficiaries in emergency cases. See 38 
U.S.C. § 1784; 38 C.F.R. §§ 17.37, 17.43, 17.95, 17.102. VA is also 
authorized to provide care and services during certain disasters and 
emergencies. See 38 U.S.C. § 1785; 38 C.F.R. § 17.86. 

[36] According to a VA General Counsel memorandum (Guidance on Entering 
into Mutual Aid Agreements, July 23, 2003), hospitals can also enter 
into mutual aid agreements in which VA hospitals and local entities 
agree to assist each other during disasters and emergencies. These 
agreements often include provisions to accept patients from other 
hospitals if the transferring hospital has an overwhelming number of 
patients or if the transferring facility does not have the resources 
for patients who require specialized medical treatment. However, these 
mutual aid agreements must state that the agreement is limited by 
certain VA obligations that may take precedence over the agreement to 
assist local hospitals during an emergency, such as its obligations 
under the National Disaster Medical System and its obligations to 
assist DOD during a time of war or national emergency. 

[37] The Modular Emergency Medical System provides detailed standards 
for a system of medical care that can be expanded as the need arises. 
It provides a framework for the organization of care, particularly for 
setting up predetermined, special-use alternate care sites. It provides 
information on what general kinds of care are provided and where and 
who will provide care. 

[38] The seven categories of health care professionals are physicians, 
registered nurses, marriage and family therapists, medical and public 
health social workers, mental health and substance abuse social 
workers, psychologists, and mental health counselors. 

[39] A ventilator mechanically moves oxygen into and out of the lungs 
of a patient who is physically unable to breathe on his or her own, or 
whose breathing is insufficient to maintain life. 

[40] The pandemic influenza Web site can be accessed at [hyperlink, 
http://www.pandemicflu.gov]. This Web site is managed by HHS. 

[41] Officials from the remaining state reported that they did not know 
how many beds were available statewide above the current daily staffed 
bed capacity. 

[42] Centers for Medicare & Medicaid Services (CMS), through the 
Medicare and Medicaid programs, is a significant source of 
reimbursement for medical services, including those provided in 
hospital settings. Additionally, private insurers typically are guided 
by CMS policies regarding reimbursement. 

[43] On CMS's Web site, the agency provides some broad guidance on its 
role during an emergency. See [hyperlink, 
http://www.cms.hhs.gov/SurveyCertEmergPrep], Provider Survey and 
Certification Frequently Asked Questions, Declared Public Health 
Emergencies - All Hazards Health Standards and Quality Issues (Sept. 
30, 2007). 

[44] Pub. L. No. 104-191, 110 Stat. 1936; 45 C.F.R. Parts 160 and 164. 

[45] Pub. L. No. 99-272, 100 Stat. 164 (1986) (codified, as amended, at 
42 U.S.C. § 1395dd). 

[46] An individual's authorization is not required to use and disclose 
protected health information for some purposes, such as treatment, 
payment, and health care operations. 45 C.F.R. § 164.506(c). 

[47] Social Security Act §1135(b) (codified at 42 U.S.C. §1320b-5). 
These waivers are limited to a 72-hour period that begins when a 
hospital implements a disaster protocol. 

[48] See [hyperlink, http://www.hhs.gov/katrina/ssawaiver.html]. 

[49] MRC is a federal program within the U.S. Surgeon General's Office, 
which is in HHS. MRC units are community-based and organize and utilize 
volunteers to, among other things, prepare for and respond to 
emergencies. MRC volunteers include medical and public health 
professionals as well as other community members such as interpreters 
and legal advisers. 

[50] DMAT is an HHS program in which volunteer medical personnel 
provide medical care during a disaster. DMATs supplement local medical 
care until other federal resources can be mobilized and deployed to 
disaster sites. 

[51] By comparison, seasonal influenza in the United States generally 
results in 200,000 hospitalizations annually. 

[52] Department of Health and Human Services, HHS Pandemic Influenza 
Plan (Washington, D.C.: Nov. 2005). 

[53] The group brought together experts in law, medicine, policy 
making, and ethics with representatives from medical facilities and 
city, county, and state government. 

[54] The task force included officials from DHS, HHS, ASPR, CDC, DOD, 
and VA. See Asha V. Devereaux, et al., "Definitive Care for the 
Critically Ill During a Disaster: A Framework for Allocation of Scarce 
Resources in Mass Critical Care: From a Task Force for Mass Critical 
Care Summit Meeting, January 26 to 27, 2007, Chicago, Il.," Chest 
(2008): 133, 51-66. 

[55] The Joint Commission is an independent, nonprofit organization 
responsible for evaluating and accrediting over 15,000 U.S. health care 
organizations and programs, including Department of Defense and 
Department of Veterans Affairs hospitals. 

[56] While the Hospital Preparedness Program awards funds annually to 
62 entities--the 50 states, 4 municipalities including the District of 
Columbia, 5 U.S. territories, and 3 Freely Associated States of the 
Pacific--we limited our review to the 50 states. 

[57] Four of the states we reviewed provided sentinel indicator 
information as of April 2007, one state as of August 2007, and another 
state as of September 2007. 

[58] The 2006 program year for the Hospital Preparedness Program was 
September 1, 2006, to August 31, 2007. The 2007 program year is 
September 1, 2007, to August 8, 2008. 

[59] Sentinel indicators are smaller component tasks of critical 
benchmarks, which measure program capacity-building efforts. For 
example, for the benchmark "Surge Capacity; Beds," one of the sentinel 
indicators is the number of additional hospital beds for which a 
recipient could make patient care available within 24 hours. ASPR 
requires that states report on 15 sentinel indicators, 2 of which are 
not related to medical surge. 

[60] Two of the 15 indicators--total number of hospitals statewide and 
total population statewide--were used as denominators to analyze the 5 
indicators. We were unable to identify or create any usable criteria 
with which to evaluate the remaining 8 indicators. 

[61] 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. This selection 
criterion 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. 

[End of section] 

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