Hospital Disaster Preparedness Discussion

Hospitals Rising to the Challenge:
The First Five Years of the U.S. Hospital Preparedness Program
and Priorities Going Forward
Evaluation Report | March 2009
Sponsored by the U.S. Department of Health and Human Services under Contract #HHSO100200700038C
The Center for Biosecurity is an independent, nonprofit organization of the University of Pittsburgh Medical Center (UPMC).
The Center’s multidisciplinary professional staff, with experience in government, medicine, public health, bioscience, law, and
the social sciences, works to affect policy and practice in ways that lessen the illness, death, and civil disruption that would
follow large-scale epidemics, whether they occur naturally or result from the use of a biological weapon. Experts at the Center
publish research findings regularly and are consulted by government agencies, businesses, academia, and the media for independent analyses of issues pertaining to national and global epidemic preparedness and response.
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Acknowledgments
This work was commissioned by the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response (ASPR), under Contract No. HHSO100200700038C. This report would not
have been possible without the more than 100 dedicated and committed hospital and state preparedness planners and other experts who contributed their time to provide the Center for Biosecurity project team with critical
insight into the state of U.S. hospital preparedness, or without the participants of the June 2008 Issue Analysis
Meeting in Baltimore, Maryland. The project team would also like to give special thanks to the leadership and
staff of the ASPR Office of Preparedness and Emergency Operations components of the Hospital Preparedness
Program and State and Local Evaluation for their guidance and support in the development of this report.
Suggested Citation
Toner E, Waldhorn R, Franco C, Courtney B, Rambhia K, Norwood A, Inglesby TV, O’Toole T. Hospitals Rising
to the Challenge: The First Five Years of the U.S. Hospital Preparedness Program and Priorities Going Forward.
Prepared by the Center for Biosecurity of UPMC for the U.S. Department of Health and Human Services under
Contract No. HHSO100200700038C. 2009.
Hospitals Rising to the Challenge:
The First Five Years of the U.S. Hospital Preparedness Program
and Priorities Going Forward
Evaluation Report | March 2009
Project Team
Center for Biosecurity of UPMC
Eric Toner, MD (Principal Investigator)
Senior Associate
Richard Waldhorn, MD (Co-Principal Investigator)
Distinguished Scholar
Crystal Franco (Project Manager)
Senior Analyst
Brooke Courtney, JD, MPH
Associate
Kunal Rambhia
Analyst
Ann Norwood, MD, COL, USA, MC (Ret.)
Senior Associate
Thomas V. Inglesby, MD
Deputy Director and Chief Operating Officer
Tara O’Toole, MD, MPH
Director and Chief Executive Officer
Project Contacts: Eric Toner, MD, and Richard Waldhorn, MD
Hospitals Rising to the Challenge | March 2009
Contents
List of Tables and Figures……………………………………………………………………………………………………………iii
Executive Summary……………………………………………………………………………………………………………………. v
I. Project Overview
Summary………………………………………………………………………………………………………………………………. 1
Methodology…………………………………………………………………………………………………………………………. 2
II. State of U.S. Hospital Preparedness Prior to the Hospital Preparedness Program
Historical Context…………………………………………………………………………………………………………………… 7
Pre-HPP Hospital Preparedness Research…………………………………………………………………………………. 11
III. History of the Hospital Preparedness Program
Legislative and Funding History………………………………………………………………………………………………. 17
Program Guidance (FY2002–FY2008)……………………………………………………………………………………….. 19
Impact of Guidance Evolution on Data Collection and Reporting………………………………………………… 20
Hospital Preparedness Research Conducted after HPP Implementation……………………………………….. 21
IV. Key Findings
1. Disaster preparedness of individual hospitals has improved significantly
throughout the country since the start of the HPP………………………………………………………………….. 23
2. The emergence of Healthcare Coalitions is creating a foundation for
U.S. healthcare preparedness. ……………………………………………………………………………………………. 36
3. Healthcare planning for catastrophic emergencies is in early stages; progress
will require additional assistance and direction at the national level…………………………………………. 46
4. Surge capacity and capability goals, assessment of training, and analysis of
performance during actual events and realistic exercises are the most useful
indicators for measuring preparedness………………………………………………………………………………… 55
V. Conclusions
1. The HPP has improved the resilience of U.S. hospitals and communities and
increased their capacity to respond to “common medical disasters.”………………………………………. 57
2. The HPP should focus on building, strengthening, and linking Healthcare
Coalitions to lay the foundation for a national disaster health and medical
response system……………………………………………………………………………………………………………….. 58
3. Administrative adjustments to the HPP could improve the program’s
effectiveness and efficiency. ………………………………………………………………………………………………. 59
4. To prepare the nation to respond to catastrophic emergencies, HHS should
provide continued leadership to assist states in their efforts to address the many
procedural, ethical, legal, and practical problems posed by a shift to disaster
standards and ACFs that is required when demand for care overwhelms available resources……… 60
5. Catastrophic emergency preparedness is a national security issue and requires
the continued funding of the HPP………………………………………………………………………………………… 61
Center for Biosecurity of UPMC
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Hospitals Rising to the Challenge | March 2009
Appendix A. List of Acronyms……………………………………………………………………………………………………. 63
Appendix B. Center for Biosecurity Descriptive Framework for Healthcare
Preparedness for Mass Casualty Events: The Framework and Crosswalk of
Elements of Preparedness………………………………………………………………………………………. 65
Appendix C. Map of Working Group Participants Contacted for Participation…………………………………. 79
Appendix D. HPP Guidance Terminology by Year…………………………………………………………………………. 81
Appendix E. Summary of HPP Program Guidance: FY2002–FY2008………………………………………………. 83
Appendix F.
Summary of Studies on Hospital Preparedness Since the Establishment
of the HPP by Year…………………………………………………………………………………………………. 87
Center for Biosecurity of UPMC
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Hospitals Rising to the Challenge | March 2009
List of Tables and Figures
Table 1. Number of Virtual Working Group Participants by Sector………………………………………………….. 4
Table 2. Studies on Pre-HPP Hospital Preparedness by Year………………………………………………………….. 12
Table 3. Hospital Preparedness Program Funding: FY2002–FY2009……………………………………………….. 18
Figure 1. Timeline of Significant Events for Healthcare Preparedness: 1989–2007……………………………… 9
Figure 2. Percent HPP Hospital Participation by Reporting States, Municipalities,
and Territories: 2006 (n = 58)………………………………………………………………………………………… 19
Figure 3. Percentage of Hospitals with Redundant Communications Capabilities by
Number of HPP-Participating States, Municipalities, and Territories: 2006
(n = 58)………………………………………………………………………………………………………………………. 30
Figure 4. Percent Hospital Use of Corrective Actions/Improvement Plans Following a
Drill or Exercise by Number of HPP-Participating States, Municipalities, and
Territories: 2006 (n = 58)………………………………………………………………………………………………. 36
Figure 5. HHS Medical Surge Capacity and Capability (MSCC) Framework………………………………………. 39
Figure 6. Multi-Agency Coordination (MAC) Model for Regional Healthcare
Emergencies ………………………………………………………………………………………………………………. 42
Figure 7. Percentage of HPP-Participating States, Municipalities, and Territories with
a Functional ESAR-VHP System that Allows Volunteer Health Professionals
to Register for Work in Hospitals or Other Facilities during Emergencies: 2006
(n = 62)………………………………………………………………………………………………………………………. 45
Figure 8. Administrative and Clinical Adaptations to Resource-Poor Situations…………………………………. 48
Center for Biosecurity of UPMC
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Hospitals Rising to the Challenge | March 2009
Executive Summary
Executive Summary
Hospitals are the backbone of the healthcare response to common medical disasters (i.e., mass casualty events
that occur with relative frequency, overwhelm a single hospital, and require a communitywide health response)
and, in particular, to catastrophic emergencies, such as an influenza pandemic or large-scale aerosolized anthrax
attack. The need for hospitals to be prepared to respond to disasters has increasingly become a priority for hospital leaders. They have been influenced by events such as the 2001 terrorist attacks and Hurricane Katrina and
the increased emphasis placed by accreditation organizations and regulatory agencies on the importance of such
disasters.
Established by the U.S. Department of Health and Human Services (HHS) in 2002, the goal of the Hospital
Preparedness Program (HPP)1 is to enhance the ability of hospitals and healthcare systems to prepare for and
respond to bioterror attacks on civilians and other public health emergencies, including pandemic influenza and
natural disasters. Current HPP priorities include strengthening hospital capabilities in the areas of interoperable communication systems, bed tracking, personnel management, fatality management planning, and hospital
evacuation planning. Past priorities include improving bed and personnel surge capacity, decontamination capabilities, isolation capacity, pharmaceutical supplies, training, education, drills, and exercises.
The HPP was initially administered by the Health Resources and Services Administration (HRSA). Congress directed the transfer of the HPP to the Office of the Assistant Secretary for Preparedness and Response (ASPR) under
the 2006 Pandemic and All-Hazards Preparedness Act (PAHPA).2 All 50 states, as well as the District of Columbia,
the nation’s three largest municipalities (Chicago, Los Angeles, and New York City), the Commonwealths of Puerto
Rico and the Northern Mariana Islands, three territories (American Samoa, Guam, and the U.S. Virgin Islands),
Micronesia, the Marshall Islands, and Palau, have received over $2 billion in HPP funding through grants, partnerships, and cooperative agreements since 2002.
In 2007, ASPR contracted with the Center for Biosecurity of the University of Pittsburgh Medical Center (UPMC)
(Center) to conduct an assessment of U.S. hospital preparedness and to develop recommendations for evaluating
and improving future hospital preparedness efforts. The first deliverable was the Center’s Descriptive Framework
for Healthcare Preparedness for Mass Casualty Events,3 which is a description of the most important components
of preparedness for mass casualty response at the local and regional hospital and healthcare system levels (Appendix B). Hospitals Rising to the Challenge: The First Five Years of the U.S. Hospital Preparedness Program and
Priorities Going Forward is the second deliverable under the contract. It is the Center’s assessment of the impact
of the HPP on hospital preparedness from the time of the program’s establishment in 2002 through mid-2007, as
well as our preliminary recommendations for improving the state of U.S. hospital preparedness going forward.
This evaluation report is based on extensive analyses of the published literature, government reports, and HPP
program assessments, as well as on detailed conversations with 133 health officials and hospital professionals
representing every state, the largest cities, and major territories of the U.S.
1
2
3
The original name of the program was the National Bioterrorism Hospital Preparedness Program (NBHPP).
Public Law No. 109-417.
Toner E, Waldhorn R, Franco C, et al. Descriptive Framework for Healthcare Preparedness for Mass Casualty Events. Prepared by
the Center for Biosecurity of UPMC for the U.S. Department of Health and Human Services under Contract No.
HHSO100200700038C. 2008.
Center for Biosecurity of UPMC
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Hospitals Rising to the Challenge | March 2009
Executive Summary
Key Findings
Disaster preparedness of individual hospitals has improved significantly throughout the country
since the start of the HPP.
Since 2002, individual hospitals throughout the U.S. have made considerable progress in disaster preparedness.
For the most part, hospital senior leadership is actively supporting and participating in preparedness activities,
and disaster coordinators within hospitals have given sustained attention to preparedness and response planning
efforts. Hospital emergency operations plans (EOPs) have become more comprehensive and, in many locations,
are coordinated with community emergency plans and local hazards. Disaster training has become more rigorous
and standardized; hospitals have stockpiled emergency supplies and medicines; situational awareness and communications are improving; and exercises are more frequent and of higher quality.
The emergence of Healthcare Coalitions is creating a foundation for U.S. healthcare preparedness.
One of the most significant factors contributing to strengthened healthcare preparedness is the emergence of
Healthcare Coalitions, which, since the establishment of the HPP, have involved collaboration and networking
among hospitals and between hospitals, public health departments, and emergency management and response
agencies. These coalitions represent the beginning of a coordinated communitywide approach to medical
disaster response. If they can continue to be developed and strengthened around the country, coalitions would
logically become the foundation of a more robust national disaster health and medical response capacity, as
envisioned in Homeland Security Presidential Directive 21 (HSPD-21),4 to respond to catastrophic emergencies
in which one community’s Healthcare Coalition could come to the assistance of another’s coalition. The HPP has
played a critically important role in catalyzing the creation of these coalitions, which did not exist in most communities before the program’s establishment.
Healthcare planning for catastrophic emergencies is in early stages; progress will require additional
assistance and direction at the national level.
The U.S. healthcare system is not currently capable of effectively responding to a sudden surge in demand for
medical care that would occur during catastrophic events, such as those described in the Department of Homeland Security (DHS) National Planning Scenarios.5 Emergencies of this magnitude would overwhelm the medical
capabilities of communities, regions, or the entire country and require drastic departures from customary healthcare practices. Such a “phase shift” in the provision of care to disaster standards would be unlike anything that
has ever been done in the U.S. It also is extremely difficult to plan for because it involves the development of
clinical standards of care for disasters and a process for implementing such standards, both of which raise complex clinical, legal (federal and state), and ethical issues. Most hospitals and states have begun to address this
problem and have found the Agency for Healthcare Research and Quality (AHRQ)/ASPR guidance documents,6,7
to be very useful, but none are adequately prepared. While many issues related to developing and implementing
disaster standards are ultimately state responsibilities, continued national leadership and direction are essential
for sustained state and local progress in catastrophic emergency planning.
4
5
6
7
The White House. Homeland Security Presidential Directive/HSPD-21. October 18, 2007.
http://www.whitehouse.gov/news/releases/2007/10/print/20071018-10.html. HSPDs were issued by President Bush
to communicate decisions about the nation’s homeland security policies.
U.S. Department of Homeland Security (DHS). National Preparedness Guidelines.
http://www.dhs.gov/xlibrary/assets/National_Preparedness_Guidelines.pdf. September 2007.
Agency for Healthcare Research and Quality (AHRQ), Assistant Secretary for Preparedness and Response (ASPR). Altered
Standards of Care in Mass Casualty Events. Prepared by Health Systems Research Inc. under Contract No. 290-04-0010.
AHRQ Publication No. 05-0043. Rockville, MD: Agency for Healthcare Research and Quality. April 2005.
Phillips SJ, Knebel A, eds. Mass Medical Care with Scarce Resources: A Community Planning Guide. Prepared by Health
Systems Research, Inc. under Contract No. 290-04-0010. AHRQ Publication No. 07-0001. Rockville, MD: Agency for
Healthcare Research and Quality 2007.
Center for Biosecurity of UPMC
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Hospitals Rising to the Challenge | March 2009
Executive Summary
Surge capacity and capability goals, assessment of training, and analysis of performance during
actual events and realistic exercises are the most useful indicators for measuring preparedness.
The most useful metrics for measuring individual hospital preparedness were those that were clearly defined and
not overly burdensome for hospitals. Useful HPP metrics included numerical surge capacity and capability goals
(e.g., targets for staff, supplies, and space), training of personnel, and performance during actual events and
structured exercises. Measuring individual hospital preparedness should also be based on the Joint Commission
Standards for Emergency Management, which already significantly overlap with HPP guidances. Assessment
of Healthcare Coalition preparedness should be based on the ability of coalitions to perform critical coalition
functions, such as providing situational awareness during an event and maintaining and operating reliable and
redundant communications systems.
Conclusions
The HPP has improved the resilience of U.S. hospitals and communities and increased their capacity
to respond to “common medical disasters.”
Prior to 2002, most hospitals did not have adequate plans to handle common medical disasters, much less
catastrophic emergencies comparable to the National Planning Scenarios. Over the course of six years, the HPP
has catalyzed significant improvements in hospital preparedness for common medical disasters. Hospitals have
implemented communications systems, incident command system concepts, stockpiles of medicines and supplies, situational awareness tools, and memoranda of understanding for sharing assets and staff during disasters.
The HPP should focus on building, strengthening, and linking Healthcare Coalitions to lay the
foundation for a national disaster health and medical response system.
The development of Healthcare Coalitions has been the single most important step toward preparing the U.S.
healthcare system to respond to catastrophic disasters that require the healthcare assets of an entire region or the
country. A national system of functional Healthcare Coalitions capable of responding to such disasters is unlikely
to develop without further federal support and guidance. To be able to respond collectively to these types of
catastrophes, the coalitions would need to be coordinated and linked with each other through a nationwide
system that could effectively call upon and coordinate all necessary national assets. The development of such a
system would clearly need to be integrated with existing federal and state disaster response programs and with
the development of a more robust national disaster health and medical system, as outlined in HSPD-21.8
Administrative adjustments to the HPP could improve the program’s effectiveness and efficiency.
These changes include: transitioning the HPP grant to a multi-year project cycle, where awardees would have at
least two years to complete grant work; streamlining and coordinating all federal grants that contain guidance for
hospitals and public health agencies; creating or adopting a healthcare-specific National Incident Management
System (NIMS) training program for use by hospitals and public health agencies that participate in the HPP; and
continuing to phase in the Homeland Security Exercise and Evaluation Program (HSEEP) standards for hospital
exercises and drills in the HPP guidance.
8
The White House (2007).
Center for Biosecurity of UPMC
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Hospitals Rising to the Challenge | March 2009
Executive Summary
To prepare the nation to respond to catastrophic emergencies, HHS should provide continued
leadership to assist states in their efforts to address the many procedural, ethical, legal, and
practical problems posed by a shift to disaster standards and alternate care facilities (ACFs) that is
required when demand for care overwhelms available resources.
Hospitals and Healthcare Coalitions are struggling with how best to prepare for catastrophic emergencies that
may require a shift to disaster standards of care. While many of these issues must ultimately be addressed
and resolved at the state and local levels, states continue to struggle with some fundamental issues, including
developing clinical guidelines and procedural or legal frameworks for shifting to and using disaster standards.
HHS should continue to provide leadership and direction on these issues by: creating a resource for planners
across the U.S. to share information on approaches, guidelines, and tools for disaster standards that have been
developed by states, medical experts, professional societies, and others; convening a working group specifically
focused on implementing disaster standards of care and ACFs and on exploring the developme

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