oversight

Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but Lack Certain Capacities for Bioterrorism Response

Published by the Government Accountability Office on 2003-08-06.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

              United States General Accounting Office

GAO           Report to Congressional Committees




August 2003
              HOSPITAL
              PREPAREDNESS
              Most Urban Hospitals
              Have Emergency
              Plans but Lack Certain
              Capacities for
              Bioterrorism
              Response




GAO-03-924
                                                August 2003


                                                HOSPITAL PREPAREDNESS

                                                Most Urban Hospitals Have Emergency
Highlights of GAO-03-924, a report to the       Plans but Lack Certain Capacities for
Senate Committee on Health, Education,
Labor, and Pensions; the Senate and             Bioterrorism Response
House Committees on Appropriations; and
the House Committee on Energy and
Commerce




In the event of a large-scale                   While most urban hospitals across the country reported participating in
infectious disease outbreak, as                 basic planning and coordination activities for bioterrorism response, they
could be seen with a bioterrorist               did not have the medical equipment to handle the number of patients that
attack, hospitals and their                     would be likely to result from a bioterrorist incident. Four out of five
emergency departments would be                  hospitals reported having a written emergency response plan addressing
on the front line. Federal, state, and
local officials are concerned,
                                                bioterrorism, but many plans omitted some key contacts, such as other
however, that hospitals may not                 laboratories. Almost all hospitals reported participating in a local, state, or
have the capacity to accept and                 regional interagency disaster preparedness committee. In addition, most
treat a sudden, large increase in the           hospitals reported having provided at least some training to their personnel
number of patients, as might be                 on identification and diagnosis of disease caused by biological agents
seen in a bioterrorist attack. In the           considered likely to be used in a bioterrorist attack, such as anthrax or
Public Health Improvement Act                   botulism. In contrast, fewer than half of hospitals have conducted drills or
that was passed in 2000, Congress               exercises simulating response to a bioterrorist incident. Hospitals also
directed GAO to examine                         reported that they lacked the medical equipment necessary for a large influx
preparedness for a bioterrorist                 of patients. For example, if a large number of patients with severe
attack. In this report GAO provides             respiratory problems associated with anthrax or botulism were to arrive at a
information on the extent of
bioterrorism preparedness among
                                                hospital, a comparable number of ventilators would be required to treat
hospitals in urban areas in the                 them. Yet half of hospitals reported having fewer than six ventilators per 100
United States.                                  staffed beds. In general, larger hospitals reported more planning and training
                                                activities than smaller hospitals.
To conduct this work, GAO
surveyed over 2,000 urban                       Representatives from the American Hospital Association provided oral
hospitals and about 73 percent                  comments on a draft of this report, which GAO incorporated as appropriate.
provided responses addressing                   They generally agreed with the findings.
emergency preparedness. The
survey collected information on
                                                Urban Hospitals with Ventilator Capabilities, per 100 Staffed Beds
hospital preparedness for
bioterrorism, such as data on
planning activities, staff training,             Ventilators                                                         Percentage of hospitals
and capacity for response.                       Less than 2 ventilators                                                                 9.0
                                                 2 to less than 5 ventilators                                                           33.9
                                                 5 to less than 10 ventilators                                                          39.7
                                                 10 or more ventilators                                                                 17.4
                                                 Total                                                                                 100.0

                                                Source: GAO.

                                                Note: Data are from GAO’s 2002 survey of hospitals and their emergency departments. Responses
                                                were weighted to provide estimates for the universe of hospitals.




www.gao.gov/cgi-bin/getrpt?GAO-03-924.

To view the full product, including the scope
and methodology, click on the link above.
For more information, contact Marcia Crosse
on (202) 512-7119.
Contents


Letter                                                                                              1
                       Results in Brief                                                             2
                       Background                                                                   3
                       Hospitals Reported Planning for Bioterrorism Response but Do Not
                         Have Certain Medical Capacities to Handle a Large Increase in
                         Patient Load                                                              8
                       Concluding Observations                                                    16
                       Comments from the American Hospital Association                            17

Appendix I             Selected Results of GAO Survey of Hospitals
                       Regarding Hospital Preparedness for Bioterrorism                           19



Appendix II            Scope and Methodology                                                      35



Appendix III           GAO Contact and Staff Acknowledgments                                      37
                       GAO Contact                                                                37
                       Acknowledgments                                                            37

Related GAO Products                                                                              38



Tables
                       Table 1: Percentage of Urban Hospitals Participating in an
                                Interagency Disaster Preparedness Committee That Also
                                Includes Members from Specified Organization                      12
                       Table 2: Urban Hospitals with Medical Equipment Capabilities, per
                                100 Staffed Beds                                                  15
                       Table 3: Characteristics of Hospitals in Survey                            20
                       Table 4: Number of Hospitals That Were Sent Survey, Number That
                                Responded to Survey, and Percentage of Hospitals That
                                Responded to Survey, by State and District of Columbia            21
                       Table 5: Percentage of Urban Hospitals with a Written Emergency
                                Response Plan Addressing Bioterrorism, by State                   23
                       Table 6: Percentage of Urban Hospitals That Reported Specifying
                                in Emergency Response Plan to Contact the Specified
                                Entities during an Emergency, by State                            25



                       Page i                           GAO-03-924 Hospital Bioterrorism Preparedness
          Table 7: Percentage of Urban Hospitals Whose Mass Casualty Plans
                   Address Bioterrorism and Describe How to Manage the
                   Specified Function, by State                                      27
          Table 8: Percentage of Urban Hospitals That Had Agreements with
                   Other Hospitals or City, County, State, and Regional
                   Organizations to Provide or Share Resources in the Event
                   of Bioterrorism, by State                                         29
          Table 9: Percentage of Urban Hospitals That Have Provided
                   Training to Staff (Services, Courses, or Self-Learning
                   Materials) to Identify and Diagnose Symptoms for the
                   Following Biological Agents, by State                             31
          Table 10: Percentage of Urban Hospitals That Participated in Mass
                   Casualty Drills Related to Biological Incidents by State          33


Figures
          Figure 1: Percentage of Urban Hospitals with a Written Emergency
                   Response Plan Addressing Bioterrorism                               9
          Figure 2: Percentage of Urban Hospitals That Reported Specifying
                   in Emergency Response Plan to Contact the Specified
                   Entity during an Emergency                                        10
          Figure 3: Percentage of Urban Hospitals Whose Emergency
                   Response Plans Addressed Bioterrorism and Included a
                   Description of How to Manage the Specified Function               11
          Figure 4: Percentage of Urban Hospitals That Have Agreements
                   with Other Hospitals or City, County, State, or Regional
                   Organizations to Provide or Share Resources in the Event
                   of Bioterrorism                                                   13
          Figure 5: Percentage of Urban Hospitals That Have Provided Staff
                   with Training (Services, Courses, or Self-Learning
                   Materials) about Identifying and Diagnosing Symptoms
                   for Each of the Following Biological Agents                       14




          Page ii                          GAO-03-924 Hospital Bioterrorism Preparedness
Abbreviations

EMS               emergency medical services
HAZMAT            hazardous materials
HHS               Department of Health and Human Services
HRSA              Health Resources and Services Administration
MSA               metropolitan statistical area
PPE               personal protective equipment
SARS              Severe Acute Respiratory Syndrome




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Page iii                                 GAO-03-924 Hospital Bioterrorism Preparedness
United States General Accounting Office
Washington, DC 20548




                                   August 6, 2003

                                   Congressional Committees

                                   In the event of a large-scale infectious disease outbreak, as could be seen
                                   with a bioterrorist attack, hospitals and their emergency departments
                                   would be on the front line. The release of a biological agent by a terrorist
                                   might not be recognized for several days, during which time a
                                   communicable disease could be spread to many people who were not
                                   initially exposed. Because hospitals are open 24 hours a day, 7 days a
                                   week, victims would be likely to seek treatment of their symptoms there,
                                   putting hospital personnel in the role of first responders. Federal, state,
                                   and local officials are concerned, however, that hospitals may not have the
                                   capacity to accept and treat a sudden, large increase in the number of
                                   patients, as might be seen in a bioterrorist attack.1 For example, these
                                   officials are concerned that this surge in patients would be likely to
                                   overwhelm emergency departments in urban areas, many of which are
                                   already operating at or above capacity.2

                                   The Public Health Improvement Act directed that we examine state and
                                   local levels of preparedness for a bioterrorist attack.3 We have previously
                                   reported on activities by federal agencies and state and local public health
                                   agencies and health care organizations, including hospitals, to prepare for
                                   and respond to bioterrorism.4 In this report we are providing you with
                                   additional information on the extent of bioterrorism preparedness among
                                   urban hospitals in the United States, specifically with respect to planning
                                   activities, staff training, and capacity for response.




                                   1
                                    U.S. General Accounting Office, Bioterrorism: Preparedness Varied Across State and
                                   Local Jurisdictions, GAO-03-373 (Washington, D.C.: Apr. 7, 2003).
                                   2
                                   For information on emergency department capacity, see U.S. General Accounting Office,
                                   Hospital Emergency Departments: Crowded Conditions Vary among Hospitals and
                                   Communities, GAO-03-460 (Washington, D.C.: Mar. 14, 2003) and The Lewin Group,
                                   Emergency Department Overload: A Growing Crisis; The Results of the AHA Survey of
                                   Emergency Department (ED) and Hospital Capacity, April 2002.
                                   3
                                    Pub. L. No. 106-505, § 102, 114 Stat. 2314, 2323 (2000).
                                   4
                                   U.S. General Accounting Office, Bioterrorism: Federal Research and Preparedness
                                   Activities, GAO-01-915 (Washington, D.C.: Sept. 28, 2001) and GAO-03-373.



                                   Page 1                                      GAO-03-924 Hospital Bioterrorism Preparedness
                   To obtain information on the extent of hospital bioterrorism preparedness,
                   we conducted a survey between May and September 2002 of 2,041 urban
                   hospitals across the country that have emergency departments. (See app. I
                   for a description of the hospitals we surveyed.) The survey asked
                   questions relating to emergency room functioning and hospital
                   bioterrorism preparedness. We reported our survey findings on emergency
                   room functioning in March 2003.5 We obtained responses to the survey
                   addressing bioterrorism preparedness from 1,482 hospitals, for a response
                   rate of 73 percent and we are providing our survey findings in the current
                   report. The survey covered key components of hospital preparedness for
                   bioterrorism, including planning activities related to communication and
                   coordination with community and state organizations (e.g., participation in
                   an interagency disaster preparedness committee); staff training; and the
                   response capacity of the facility (e.g., number of isolation beds) and of the
                   equipment (e.g., number of ventilators6). We weighted responses to adjust
                   for a lower response rate from investor-owned (for-profit) hospitals to
                   provide estimates representative of the entire universe of urban hospitals
                   we surveyed. Our report reflects hospital preparedness at the time of our
                   survey in 2002. Improvements in hospital preparedness may have occurred
                   since these data were collected. (For more detail on our scope and
                   methodology, see app. II.) We did our work from May 2002 through July
                   2003 in accordance with generally accepted government auditing
                   standards.


                   While most hospitals in urban areas across the country reported
Results in Brief   participating in basic planning and coordination activities for bioterrorism
                   response, they did not have the medical equipment to handle the large
                   increase in the number of patients that would be likely to result from a
                   bioterrorist incident. Four out of five hospitals reported having a written
                   emergency response plan addressing bioterrorism, but many plans omitted
                   some key contacts, such as laboratories outside the hospital. Almost all
                   hospitals reported participating in a local, state, or regional interagency
                   disaster preparedness committee. In addition, most hospitals reported
                   having provided at least some training to their personnel on identification
                   and diagnosis of disease caused by biological agents considered likely to
                   be used in a bioterrorist attack, such as anthrax or botulism. In contrast,


                   5
                   GAO-03-460.
                   6
                    A ventilator is a mechanical device designed to perform part or all of the work of the
                   lungs.




                   Page 2                                    GAO-03-924 Hospital Bioterrorism Preparedness
             fewer than half of hospitals have conducted drills or exercises simulating
             response to a bioterrorist incident. Hospitals also reported that they
             lacked the medical equipment necessary for a large influx of patients. For
             example, if a large number of patients were to arrive at a hospital with
             severe respiratory problems associated with anthrax or botulism, a
             comparable number of ventilators would be required to treat them. Yet
             half of hospitals reported having fewer than six ventilators per 100 staffed
             beds. In general, larger hospitals reported more planning and training
             activities than smaller hospitals.

             Representatives of the American Hospital Association provided oral
             comments on a draft of this report, which we incorporated as appropriate.
             They generally agreed with our findings.


             The resources that hospitals and their emergency departments would
Background   require for responding to a large-scale bioterrorist attack are far greater
             than those needed for everyday performance. The specific equipment,
             supplies, and facilities needed could vary depending upon what type of
             attack occurred, but many scenarios anticipate that the demand for health
             care could quickly outstrip the ability of hospitals to respond. For
             example, the TOPOFF 2000 exercise7 testing terrorism preparedness
             included a bioterrorism scenario of an attack using pneumonic plague8
             released at a public event in a single location in one city. In this exercise,
             officials found that by the third day following the covert release, 500
             persons with symptoms had been reported and antibiotic and ventilator
             shortages were beginning to occur. By the end of this day, nearly 800 cases
             were identified and over 100 persons had died. In each of the succeeding 2
             days, the situation worsened and medical care in the city was described as
             beginning to shut down, with insufficient hospital staff, beds, ventilators,
             and drugs. At the conclusion of the exercise, 1 week after the attack, an
             estimated 3,700 cases of plague had been reported, with 950 to 2,000
             deaths, including cases in other cities and abroad. In the early stages of the
             epidemic, hospitals were seeing 2 to 3 times their normal volume of


             7
              TOPOFF, so named for the involvement of top officials of the U.S. government, was a set
             of exercises assessing readiness to respond to terrorist attacks.
             8
              Pneumonic plague is a contagious disease that can be spread from person to person by
             respiratory droplet. Its symptoms include cough and fever, progressing to respiratory
             failure and shock. Pneumonic plague can be treated with some success by antibiotics if
             treatment is given within 24 hours of the first symptoms. For untreated pneumonic plague,
             mortality approaches 100 percent.




             Page 3                                   GAO-03-924 Hospital Bioterrorism Preparedness
patients and later in the exercise up to 10 times normal volumes were
arriving at hospitals. Hospitals were not able to effectively isolate patients
to prevent the spread of the disease to hospital staff.

In order to be adequately prepared for bioterrorism, hospitals would need
to have several basic capabilities, whether they possess them directly or
have access to them through regional agreements. Plans that describe how
hospitals would work with state and local officials to manage and
coordinate an emergency response would need to be in place and to have
been tested in an exercise, both at the state and local levels and at the
regional level. Regional plans can help address capacity deficiencies by
providing for the sharing, among hospitals and other community and state
agencies and organizations, of resources that, while adequate for everyday
needs, may be in short supply on a local level in an emergency. In addition,
hospitals would need to be able to communicate easily with all
organizations involved in the response as events unfold and critical
information is acquired. Staff would need to be able to recognize and
report to their state or local health department any illness patterns or
diagnostic clues that might indicate an outbreak of a disease caused by a
biological agent likely to be used by a terrorist.9 Finally, hospitals would
need to have the capacity and staff necessary to treat large numbers of
severely ill patients and limit the spread of infectious disease. They would
need adequate stores of equipment and supplies, including medications,
personal protective equipment, quarantine and isolation facilities,10 and air
handling and filtration equipment.

Many of the capabilities required for responding to a large-scale
bioterrorist attack are also required for response to naturally occurring
disease outbreaks. Such a “dual-use” response infrastructure improves the
capacity of local public health agencies to respond to all hazards. For
example, a large-scale outbreak of Severe Acute Respiratory Syndrome




9
 The Centers for Disease Control and Prevention (CDC) considers anthrax, botulism,
plague, smallpox, tularemia, and hemorrhagic fever viruses as the six biological agents that
pose the greatest potential threat for adverse public health impact and have a moderate to
high potential for large-scale dissemination.
10
  Quarantine facilities limit the freedom of movement of an individual and restrict visitors
to prevent the spread of a disease to other members of the population, and could be
created by separately housing affected individuals in an existing portion of a hospital.
Isolation facilities provide a treatment setting that includes special or separate equipment
such as air filters to limit the possibility of disease spread.




Page 4                                    GAO-03-924 Hospital Bioterrorism Preparedness
(SARS) would require many of the same capabilities that would be needed
to respond to an intentionally caused epidemic.11

Prior to our survey, efforts had been made by organizations to assist
hospitals in preparing for bioterrorism. For example, the American
Hospital Association distributed a checklist to help hospitals describe and
assess their state of preparedness for chemical and biological incidents.12
This checklist covered, for example, emergency response plans for
hospital operations during a biological or chemical disaster; emergency
preparedness training of the workers; and the hospital’s ability to increase
its capacity—for example, in terms of such items as ventilators and
decontamination equipment—in the event of a large number of patients
seeking care. Another organization, the Association for Professionals in
Infection Control and Epidemiology, developed a mass casualty disaster
plan checklist for health care facilities, including hospitals.13 This checklist
included disease surveillance activities,14 communication systems, plans
for receiving and treating casualties, and plans for the organized discharge
of nonemergency patients on short notice.

Nevertheless, in our April 2003 report,15 we noted the general lack of
guidance on what capacities hospitals should have to be prepared for
bioterrorism. We also noted that efforts to improve hospitals’ bioterrorism
response capacities must be mindful that hospitals face multiple


11
 U.S. General Accounting Office, Infectious Disease Outbreaks: Bioterrorism
Preparedness Efforts Have Improved Public Health Response Capacity, but Gaps
Remain, GAO-03-654T (Washington, D.C.: Apr. 9, 2003), U.S. General Accounting Office,
SARS Outbreak: Improvements to Public Health Capacity Are Needed for Responding to
Bioterrorism and Emerging Infectious Diseases, GAO-03-769T (Washington, D.C.:
May 7, 2003), and Severe Acute Respiratory Syndrome: Established Infectious Disease
Control Measures Helped Contain Spread, But a Large-Scale Resurgence May Pose
Challenges, GAO-03-1058T. Washington, D.C.: July 30, 2003.
12
 A. David Mangelsdorff, Chemical and Bioterrorism Preparedness Checklist (Chicago:
American Hospital Association, Oct. 3, 2001),
http://hospitalconnect.com/aha/key_issues/disaster_readiness/resources/HospitalReady.ht
ml (downloaded Apr. 22, 2003).
13
 Center for the Study of Bioterrorism & Emerging Infections, Mass Casualty Disaster
Plan Checklist: A Template for Healthcare Facilities (Washington, D.C.: Association for
Professionals in Infection Control and Epidemiology, Inc., Oct. 1, 2001),
http://www.apic.org/bioterror/checklist.doc (downloaded Apr. 23, 2003).
14
 Disease surveillance is the monitoring of health-related data to identify, prevent, and
control disease.
15
 GAO-03-373.




Page 5                                    GAO-03-924 Hospital Bioterrorism Preparedness
challenges, including having to prepare for other types of disasters and
continuing to meet the everyday needs of cities for emergency care. In that
report, among other things, we recommended that the Department of
Health and Human Services (HHS) develop specific benchmarks that
define adequate preparedness for a bioterrorist attack and can be used to
guide preparedness efforts.

Since our survey, there have been continuing efforts to assist hospitals in
bioterrorism preparedness. For example, the Joint Commission on
Accreditation of Healthcare Organizations released a report in 2003 on
strategies for creating and sustaining communitywide preparedness
systems for health care organizations, including hospitals.16 The report
outlined critical issues to be addressed in developing communitywide
preparedness and discussed federal and state responsibilities for
eliminating barriers to preparedness and for facilitating and sustaining
hospital and community-based emergency preparedness. It called for
hospitals to address the full range of potential disasters, including
terrorism, in their planning and to be aware of the specific hazards
applicable to their communities.

The federal government has also provided assistance for improving the
bioterrorism preparedness of hospitals. In January 2002 HHS announced
the availability of funding for that purpose.17 The Bioterrorism Hospital
Preparedness Program, administered by HHS’s Health Resources and
Services Administration (HRSA), provided funding in fiscal year 2002 of
approximately $125 million through cooperative agreements to states and
eligible municipalities to enhance the capacity of hospitals and associated
health care entities to respond to bioterrorism.18




16
 Joint Commission on Accreditation of Healthcare Organizations, Health Care at the
Crossroads: Strategies for Creating and Sustaining Community-wide Emergency
Preparedness Systems (Oakbrook Terrace, Il.: 2003).
17
 The funds were primarily appropriated by the Department of Defense and Emergency
Supplemental Appropriations for Recovery from and Response to Terrorist Attacks on the
United States Act, Pub. L. No. 107-117, 115 Stat. 2230, 2314 (2002), and Departments of
Labor, Health and Human Services, and Education, and Related Agencies Appropriations
Act of Fiscal Year 2002, Pub. L. No. 107-116, 115 Stat. 2186, 2198.
18
  The four eligible municipalities were Chicago, the District of Columbia, Los Angeles
County, and New York City. Funding was also provided to five American territories:
American Samoa, Guam, the Northern Marianas Islands, Puerto Rico, and the U.S. Virgin
Islands.




Page 6                                  GAO-03-924 Hospital Bioterrorism Preparedness
These noncompetitive cooperative agreements covered two phases. In the
first phase, states and municipalities applying for this funding were
required to develop a needs assessment for a comprehensive bioterrorism
preparedness program for hospitals and other health care entities, such as
community health centers, and an implementation plan, as well as to begin
initial implementation of the plan. Applications for the first phase were
due to HHS by February 25, 2002, and funding for this phase,
approximately $25 million, was awarded shortly after receipt of
applications. For the second phase, jurisdictions were required to submit
more detailed implementation plans, in which they addressed three
“critical benchmarks,” including a regional hospital plan for dealing with a
potential epidemic involving at least 500 patients. In addition, applicants
were to address four top-priority planning areas: medications and
vaccines; personal protection, quarantine, and decontamination;
communications; and biological disaster drills. Applications for the second
phase were due April 15, 2002, and the additional funding, approximately
$100 million, was awarded after HHS’s review and approval of the plans. In
March 2003, HHS announced that HRSA’s National Bioterrorism Hospital
Preparedness Program would provide funding in fiscal year 2003 of
approximately $498 million through cooperative agreements to states and
eligible municipalities.19 In response to our recommendations concerning
additional guidance, HHS noted that it is developing some additional
guidelines and templates to assist in preparedness efforts.20

In addition, the federal government has established a stockpile of
pharmaceuticals, antidotes, and medical supplies that can be delivered to
the site of a bioterrorist (or other) attack. This Strategic National Stockpile
has recently been expanded and HHS disclosed that it is planning to
purchase 2,700 ventilators by September 2003 to supplement those now
available in the stockpile. These supplies could be deployed to the site of
an attack within 12 to 36 hours following a declaration of an emergency.




19
  The four eligible municipalities are Chicago, the District of Columbia, Los Angeles
County, and New York City. Funding will also be provided to five American territories:
American Samoa, Guam, the Northern Marianas Islands, Puerto Rico, and the U.S. Virgin
Islands, and to three freely associated states of the Pacific: Marshall Islands, Micronesia,
and Palau.
20
 GAO-03-373.




Page 7                                     GAO-03-924 Hospital Bioterrorism Preparedness
                              Most hospitals in urban areas across the country reported participating in
Hospitals Reported            basic planning and coordination activities for bioterrorism response.
Planning for                  Although most hospitals reported providing at least some training to their
                              personnel on identification and diagnosis of disease caused by biological
Bioterrorism                  agents considered likely to be used in a bioterrorist attack, only about half
Response but Do Not           report they have conducted drills or exercises simulating response to a
                              bioterrorist incident. Further, few reported having acquired the medical
Have Certain Medical          equipment to handle the large increase in the number of patients that
Capacities to Handle a        would be likely to result from a bioterrorist incident.
Large Increase in
Patient Load
Most Hospitals Have           Our survey showed that hospitals have engaged in a variety of planning
Emergency Response            and coordination activities, with most having prepared an emergency
Plans Addressing              response plan addressing bioterrorism; participated in a local, state, or
                              regional interagency disaster preparedness committee; and made
Bioterrorism and Are          agreements with at least one other organization to share personnel or
Participating in Local,       equipment in the event of a bioterrorist or other mass casualty incident.
State, or Regional Planning
and Coordination              Four out of five hospitals reported having a written emergency response
Activities                    plan that specifically addresses bioterrorism (see fig. 1). Hospitals that had
                              a plan were on average around 15 percent larger than those that did not in
                              terms of number of staffed beds.21 Of those hospitals that reported not
                              having such a plan, almost all were currently developing one.




                              21
                               Staffed beds are the total facility beds set up and staffed as reported by hospitals in the
                              American Hospital Association Annual Survey of Hospitals Database 2000.




                              Page 8                                     GAO-03-924 Hospital Bioterrorism Preparedness
Figure 1: Percentage of Urban Hospitals with a Written Emergency Response Plan
Addressing Bioterrorism

                      1%
                                                    Not developing a plan



               18%                                  Developing a plan




                      81%                           Have a plan




Source: GAO.

Note: Data are from our 2002 survey of hospitals and their emergency departments. Responses were
weighted to provide estimates for the universe of hospitals.


We asked hospitals whether certain elements were specified in their
emergency response plan: contacting other response agencies and
organizations in the event of a bioterrorist incident and managing various
critical functions such as decontamination of victims. As shown in figure
2, of the hospitals that reported having an emergency response plan for
bioterrorism, approximately 90 percent reported specifying in their plan to
contact state and local government agencies, public health agencies, other
hospitals, hazardous materials (HAZMAT) teams, emergency medical
services (EMS), fire departments, or law enforcement. These entities
would be critical to mounting a larger communitywide response,
communicating with the public, investigating and controlling sources of
the outbreak, transporting patients, maintaining order, and investigating
those responsible for the bioterrorism. Hospitals that planned to contact
HAZMAT teams or public health agencies were on average around 15 and
20 percent larger, respectively, than those that did not. There were no
significant differences in average sizes of hospitals with respect to
contacting any of the other entities. Approximately 75 percent of hospitals
reported planning to contact public or private utilities, whose assistance
could be needed to increase or maintain power supplies to critical
equipment or to control water- or sewer-borne pathogens. Although
establishing contact with other laboratories that could potentially provide



Page 9                                      GAO-03-924 Hospital Bioterrorism Preparedness
additional capacity for overstretched hospital laboratories would be
critical, the percentage of hospitals planning to make that link was lowest,
at approximately 60 percent. Approximately 40 percent of hospitals
reported specifying contacting all nine types of entities listed in figure 2.

Figure 2: Percentage of Urban Hospitals That Reported Specifying in Emergency
Response Plan to Contact the Specified Entity during an Emergency



         Other laboratories                                               57.1

Public or private utilities                                                           75.8

            Other hospitals                                                                   89.3

       Other state and local                                                                   90.7
      government agencies
                   HAZMAT                                                                      90.8


                       EMS                                                                       93.4

                        Fire                                                                         94.2

          Law enforcement                                                                            94.6

     Public health agencies                                                                          94.7

                               0             20               40          60           80             100
                               Percentage of hospitals
Source: GAO.

Note: Data are from our 2002 survey of hospitals and their emergency departments. Responses were
weighted to provide estimates for the universe of hospitals. Data are presented for hospitals that
reported having an emergency response plan that addresses bioterrorism.


As shown in figure 3, most of the hospitals that reported having an
emergency response plan for bioterrorism indicated that they specified in
that plan how certain critical functions were to be managed. The functions
specified by more than 87 percent of hospitals included providing for
hospital security to control entry to and exit from all parts of the hospital;
obtaining additional staff, supplies, and pharmaceuticals to increase the
hospital’s capacity to handle a surge of patients; or planning for mass
evacuation of nonemergency patients on short notice. In general, larger
hospitals had emergency response plans that covered more of these
functions than the plans of smaller hospitals. Hospitals that reported
addressing how to obtain additional pharmaceuticals for surge capacity,
“worried well”22 management, and mass fatalities were on average around


22
 The “worried well” are people who think they may be infected but in fact are not.



Page 10                                                  GAO-03-924 Hospital Bioterrorism Preparedness
15 percent larger than those that did not. There were no significant
differences in average sizes of hospitals with respect to any of the other
functions. Approximately 77 percent of the hospitals reported addressing
the question of how to manage a large influx of the worried well and
distinguish them from victims who may be in the early stages of illness.
Approximately 50 percent of hospitals addressed the management of all of
the critical functions listed in figure 3.

Figure 3: Percentage of Urban Hospitals Whose Emergency Response Plans
Addressed Bioterrorism and Included a Description of How to Manage the Specified
Function

              Mass fatality management                                         76.7

              Worried well management                                          76.8

Obtaining additional pharmaceuticals
                                                                                      87.3
                   for surge capacity

                       Mass evacuation                                                 90.5

     Obtaining additional other supplies
                      for surge capacity                                                92.8

            Decontamination of victims                                                       94.8

               Obtaining additional staff
                      for surge capacity                                                      95.9

             Mass patient management                                                         96.1

                       Hospital security                                                      98.2
                                            0        20         40    60        80           100
                                            Percentage of hospitals
Source: GAO.

Note: Data are from our 2002 survey of hospitals and their emergency departments. Responses were
weighted to provide estimates for the universe of hospitals. Data are presented for hospitals that
reported having an emergency response plan that addressed bioterrorism.


Whether they had an emergency response plan addressing bioterrorism or
not, more than 95 percent of hospitals reported participating in a local,
state, or regional interagency disaster preparedness committee, task force,
or working group. Most commonly, these committees also included
representatives from city and county emergency medical services
organizations, fire departments, city and county offices of emergency
management, other local hospitals or medical institutions, city and county
public health or health departments and agencies, and law enforcement
organizations (see table 1). As we have previously reported,23 it was not


23
 GAO-03-373.



Page 11                                               GAO-03-924 Hospital Bioterrorism Preparedness
until after September 11, 2001, that government and hospital officials came
to view hospitals as an integral component in local planning for
responding to a terrorist event.

Table 1: Percentage of Urban Hospitals Participating in an Interagency Disaster
Preparedness Committee That Also Includes Members from Specified Organization

                                                                                     Percentage
 City and county emergency medical services organizations                                    94.0
 Fire departments                                                                            91.2
 City and county offices of emergency management                                             88.3
 Other local hospitals or other medical institutions                                         86.8
 City and county public health or health departments and agencies                            86.6
 Law enforcement organizations                                                               84.0
 State health or public health departments and agencies                                      47.0
 Professional organizations (e.g., emergency medicine organization, local
 medical society, hospital association)                                                      46.6
 State office of emergency management                                                        46.6
 Surrounding area mutual aid response organizations                                          43.9
 Public or private utilities (such as water and power)                                       37.6
 State law enforcement organizations                                                         36.7
 Board of supervisors or other elected officials                                             34.4
 Freestanding HAZMAT organizations                                                           33.2
 Public or private transportation organizations                                              31.1
 State office of emergency medical services                                                  29.8
 Federal Bureau of Investigation                                                             24.8
 Federal Emergency Management Agency                                                         21.2
 National Guard                                                                              18.3
 Centers for Disease Control and Prevention                                                  11.3
 State office of fire control                                                                10.7
 Department of Justice                                                                         8.4

Source: GAO.

Note: Data are from our 2002 survey of hospitals and their emergency departments. Responses were
weighted to provide estimates for the universe of hospitals. Data are presented for hospitals that
reported participating on an interagency disaster preparedness committee, task force, or working
group.




Page 12                                     GAO-03-924 Hospital Bioterrorism Preparedness
                               Another planning and coordination activity that hospitals reported on in
                               our survey was their participation in agreements to share or provide
                               resources in the event of a bioterrorist or other mass casualty incident. We
                               asked about agreements at the hospital, city, county, state, and regional
                               levels. The survey results indicated that hospitals mostly coordinated with
                               other hospitals, about half coordinated with the local government, and
                               about one-third coordinated at the state or regional level to provide or
                               share resources. About 70 percent of hospitals reported that they had
                               agreements, such as memoranda of understanding or mutual aid
                               agreements, with other hospitals to provide or share personnel,
                               equipment, or other resources (see fig. 4). Fewer (between 37 and 54
                               percent) hospitals had agreements with regional, state, county, or city
                               organizations (fig. 4). In general, hospitals that had agreements with other
                               organizations were larger than those that did not. Hospitals that had
                               agreements with other hospitals or with city organizations were on
                               average around 10 percent larger than hospitals that did not. Fewer than
                               20 percent of hospitals had agreements with entities at all five levels.

                               Figure 4: Percentage of Urban Hospitals That Have Agreements with Other
                               Hospitals or City, County, State, or Regional Organizations to Provide or Share
                               Resources in the Event of Bioterrorism




                               Note: Data are from our 2002 survey of hospitals and their emergency departments. Responses were
                               weighted to provide estimates for the universe of hospitals.


Staff Training on Biological   Approximately 7 out of 10 hospitals reported that their staff had received
Agents Was Reported to Be      training (services, courses, or self-learning materials) for identifying and
Widespread, While              diagnosing illness caused by all six biological agents that CDC has stated
                               would be most likely to be used in a bioterrorist incident (see fig. 5).
Hospital Participation in      Hospitals that reported training activities for all of the biological agents
Drills Was Less Common         were on average around 15 percent larger than hospitals that did not. A
                               greater percentage of hospitals reported that staff had received training for
                               anthrax or smallpox (around 90 percent or more) than for plague or



                               Page 13                                     GAO-03-924 Hospital Bioterrorism Preparedness
                             botulism (approximately 80 percent) or tularemia or hemorrhagic fever
                             viruses (approximately 70 percent). However, the extensiveness of the
                             reported training cannot be determined from our survey.

                             Figure 5: Percentage of Urban Hospitals That Have Provided Staff with Training
                             (Services, Courses, or Self-Learning Materials) about Identifying and Diagnosing
                             Symptoms for Each of the Following Biological Agents

                             Hemorrhagic                                                           71.2
                             fever viruses

                                  Tularemia                                                        71.8


                                  Botulism                                                                 80.8


                                    Plague                                                                 80.9


                                  Smallpox                                                                        87.9


                                    Anthrax                                                                              93.0
                                              0              20         40              60                80              100
                                              Percentage of hospitals
                             Source: GAO.

                             Note: Data are from our 2002 survey of hospitals and their emergency departments. Responses were
                             weighted to provide estimates for the universe of hospitals.


                             About half of all hospitals reported participating in drills or tabletop
                             exercises simulating a biological attack during the past 2 years.24 Hospitals
                             that reported participating in biological drills were on average around 20
                             percent larger than hospitals that did not. Of all of the hospitals that
                             participated in biological drills or exercises, approximately 80 percent
                             carried out these activities with other organizations.


Hospitals Reported           The availability of medical equipment needed for bioterrorism response
Insufficient Medical         varied greatly among hospitals, and hospitals reported that they did not
Equipment to Handle a        have the capacity to respond to the large increase in the number of
                             patients that would be likely to result from a bioterrorist incident with
Large Increase in Patients   mass casualties (see table 2). For example, if a large number of patients
                             were to arrive at a hospital with severe respiratory problems associated
                             with anthrax or botulism, a comparable number of ventilators would be
                             required to treat them. However, half of the hospitals had, per 100 staffed


                             24
                              A tabletop exercise is a type of simulation in which participants discuss scenarios and
                             responses around a table or similar setting.




                             Page 14                                     GAO-03-924 Hospital Bioterrorism Preparedness
beds, fewer than six ventilators, three or fewer personal protective
equipment (PPE) suits, fewer than four isolation beds, or the ability to
handle fewer than six patients per hour through a 5-minute
decontamination shower. More specifically, fewer than 31 percent of
hospitals could handle 10 or more patients per hour through a 5-minute
decontamination shower per 100 staffed beds, and fewer than 10 percent
had 10 or more isolation beds per 100 staffed beds. Almost 40 percent of
the hospitals had fewer than two PPE suits per 100 staffed beds, and
almost 10 percent had fewer than two ventilators per 100 staffed beds.
Hospital officials have told us that bioterrorism preparedness is expensive
and they are reluctant to create capacity that is not needed on a routine
basis and may never be needed at a particular facility.25

Table 2: Urban Hospitals with Medical Equipment Capabilities, per 100 Staffed Beds

                                                                       Percentage of
                                                                           hospitals
 Ventilators
     Less than 2 ventilators                                                      9.0
     2 to less than 5 ventilators                                                33.9
     5 to less than 10 ventilators                                               39.7
     10 or more ventilators                                                      17.4
 Total percentage of hospitals                                                   100
 Personal protective equipment (PPE) suits
     Less than 2 PPE suits                                                       38.2
     2 to less than 5 PPE suits                                                  24.8
     5 to less than 10 PPE suits                                                 16.6
     10 or more PPE suits                                                        20.3
 Total percentage of hospitals                                                   100a
 Isolation beds
     Less than 2 isolation beds                                                  18.6
     2 to less than 5 isolation beds                                             47.3
     5 to less than 10 isolation beds                                            24.6
     10 or more isolation beds                                                    9.5
 Total percentage of hospitals                                                   100




25
 GAO-03-373.




Page 15                                 GAO-03-924 Hospital Bioterrorism Preparedness
                                                                                              Percentage of
                                                                                                  hospitals
                   Number of patients per hour through 5 minute decontamination shower
                     Less than 2 patients per hour                                                       15.3
                     2 to less than 5 patients per hour                                                  25.8
                     5 to less than 10 patients per hour                                                  28.4
                     10 or more patients per hour                                                        30.5
                   Total percentage of hospitals                                                          100

               Source: GAO.

               Note: Data are from our 2002 survey of hospitals and their emergency departments. Responses were
               weighted to provide estimates for the universe of hospitals.
               a
               Does not total to 100 percent due to rounding.


               As concerns about bioterrorism have intensified over the past few years,
Concluding     hospitals across the nation have been working to increase their
Observations   preparedness for responding to such events. The staff and equipment that
               hospitals would require to respond to a bioterrorist attack with mass
               casualties are far greater than what are needed for everyday performance.
               Meeting those needs fully could be extremely difficult because
               bioterrorism preparedness is expensive and hospitals are reluctant to
               create capacity that is not needed on a routine basis and may never be
               used. In addition, along with a hospital’s ability to meet the routine needs
               of the community, needs for additional capacity for responding to
               bioterrorism emergencies must be balanced with the need to be prepared
               for all types of emergencies. Hospital officials have recognized that their
               facilities are an essential component of our nation’s bioterrorism
               preparedness and have begun planning and training efforts to increase
               their response capacity. Most hospitals, however, still lack equipment,
               medical stockpiles, and quarantine and isolation facilities for even a small-
               scale response. The additional funding that is to be provided under the
               National Bioterrorism Hospital Preparedness Program in fiscal year 2003
               can be used to help hospitals address these issues. The additional
               guidance from HHS, in response to our earlier recommendations, may also
               be helpful in assisting hospitals to better determine what specific response
               capacities they need to ensure.




               Page 16                                      GAO-03-924 Hospital Bioterrorism Preparedness
                    Representatives from the American Hospital Association provided oral
Comments from the   comments on a draft of this report. The officials generally agreed with our
American Hospital   findings and stated that this was a good and useful report providing
                    helpful information on hospital preparedness. They commended us for the
Association         high response rate to the survey, stating that this provided a more
                    comprehensive picture of hospital activities than was available elsewhere.
                    The officials suggested that the report make greater reference to the lack
                    of specific benchmarks for hospitals to use in planning, provide additional
                    context on the range of possible events that hospitals must consider in
                    their planning, and refer readers more specifically to prior GAO
                    recommendations on bioterrorism preparedness. We have added
                    additional material to clarify these points. The officials also provided
                    technical remarks, which we have incorporated where appropriate.


                    We are sending copies of this report to the Secretary of HHS, the
                    Administrator of HRSA, and other interested officials. We will also provide
                    copies to others upon request. In addition, the report will be available at
                    no charge on GAO’s Web site at http://www.gao.gov.

                    If you or your staffs have any questions about this report, please call me at
                    (202) 512-7119. Key contributors are listed in appendix III.




                    Marcia Crosse
                    Acting Director, Health Care—Public
                     Health and Science Issues




                    Page 17                            GAO-03-924 Hospital Bioterrorism Preparedness
List of Committees

The Honorable Judd Gregg
Chairman
The Honorable Edward M. Kennedy
Ranking Minority Member
Committee on Health, Education, Labor, and Pensions
United States Senate

The Honorable Ted Stevens
Chairman
The Honorable Robert C. Byrd
Ranking Minority Member
Committee on Appropriations
United States Senate

The Honorable W.J. “Billy” Tauzin
Chairman
The Honorable John D. Dingell
Ranking Minority Member
Committee on Energy and Commerce
House of Representatives

The Honorable C.W. Bill Young
Chairman
The Honorable David Obey
Ranking Minority Member
Committee on Appropriations
House of Representatives




Page 18                         GAO-03-924 Hospital Bioterrorism Preparedness
              Appendix I: Selected Results of GAO Survey
Appendix I: Selected Results of GAO Survey
              of Hospitals Regarding Hospital Preparedness
              for Bioterrorism


of Hospitals Regarding Hospital
Preparedness for Bioterrorism
              This appendix describes the characteristics of the short-term, nonfederal,
              general medical and surgical hospitals in metropolitan statistical areas
              (MSA) in the United States that had emergency departments in 2000 that
              we surveyed, and summarizes results by state. We sent the questionnaires
              to 2,041 hospitals that met these criteria—20 did not have emergency
              departments in fiscal year 2001 or were closed, for a total of 2,021
              hospitals. We obtained responses to the survey from 1,489 hospitals, for an
              overall response rate of about 74 percent. However, 7 of these hospitals
              did not return the section of the survey addressing emergency
              preparedness, leaving 1,482, for a response rate of about 73 percent for the
              questions of concern for the current report. We weighted responses to
              adjust for a lower response rate from investor-owned (for-profit) hospitals
              to provide estimates representative of the entire universe of 2,021
              hospitals in MSAs.

              The following tables show selected survey information on the
              characteristics of the survey universe (table 3), response rates for
              hospitals by state for all states and the District of Columbia (table 4),
              planning and coordination activities (tables 5 through 8), and training
              activities (tables 9 and 10), for states that had at least 10 hospitals respond
              and a response rate of at least 50 percent (tables 4-10). All data in tables
              are weighted to provide estimates for the universe of 2,021 hospitals in
              MSAs.




              Page 19                                 GAO-03-924 Hospital Bioterrorism Preparedness
Appendix I: Selected Results of GAO Survey
of Hospitals Regarding Hospital Preparedness
for Bioterrorism




Table 3: Characteristics of Hospitals in Survey

                                                 Number of hospitals                      Percentage
    Population of hospital’s MSA
      2.5 million or more                                             545                            27
      1 million to less than 2.5 million                              584                            29
      Less than 1 million                                             892                            44
      Total number of hospitals                                     2,021                           100
    Ownership type
      Private, not-for-profit                                       1,460                            72
      Investor-owned (for-profit)                                     311                            15
      Public (nonfederal)                                             250                            12
      Total number of hospitals                                     2,021                           100
    Teaching hospital
      Yes                                                             713                            35
      No                                                            1,308                            65
      Total number of hospitals                                     2,021                           100
                                a
    Number of staffed beds
      Less than 100                                                   331                            16
      100 to less than 200                                            617                            31
      200 to less than 300                                            453                            22
      300 or more                                                     620                            31
      Total number of hospitals                                     2,021                           100

Source: GAO.

Note: Data are from our 2002 survey of hospitals and their emergency departments. Responses were
weighted to provide estimates for the universe of hospitals. Percentages may not total 100 owing to
rounding.
a
 Staffed beds are total facility beds set up and staffed at the end of the reporting period as reported by
hospitals in the American Hospital Association Annual Survey Database 2000.




Page 20                                         GAO-03-924 Hospital Bioterrorism Preparedness
Appendix I: Selected Results of GAO Survey
of Hospitals Regarding Hospital Preparedness
for Bioterrorism




Table 4: Number of Hospitals That Were Sent Survey, Number That Responded to
Survey, and Percentage of Hospitals That Responded to Survey, by State and
District of Columbia

                            Number of Number of hospitals              Percentage of
                    hospitals that were  that responded                hospitals that
State                     sent surveys          to survey        responded to survey
Alabama                               34                    24                     71
Alaska                                 3                     2                     67
Arizona                               27                    19                     70
Arkansas                              21                    15                     71
California                           173                   109                     63
Colorado                              25                    19                     76
Connecticut                           24                    21                     88
Delaware                               1                     1                    100
DC                                     7                     6                     86
Florida                              129                    89                     69
Georgia                               58                    41                     71
Hawaii                                 6                     4                     67
Idaho                                  5                     5                    100
Illinois                             106                    83                     78
Indiana                               52                    42                     81
Iowa                                  20                    13                     65
Kansas                                19                    12                     63
Kentucky                              26                    21                     81
Louisiana                             58                    28                     48
Maine                                  7                     5                     71
Maryland                              36                    26                     72
Massachusetts                         44                    37                     84
Michigan                              74                    53                     72
Minnesota                             33                    25                     76
Mississippi                           16                    12                     75
Missouri                              57                    37                     65
Montana                                3                     2                     67
Nebraska                               9                     8                     89
Nevada                                 5                     4                     80
New Hampshire                          9                     7                     78
New Jersey                            60                    48                     80
New Mexico                            10                     6                     60




Page 21                                 GAO-03-924 Hospital Bioterrorism Preparedness
Appendix I: Selected Results of GAO Survey
of Hospitals Regarding Hospital Preparedness
for Bioterrorism




                            Number of Number of hospitals              Percentage of
                    hospitals that were  that responded                hospitals that
 State                    sent surveys          to survey        responded to survey
 New York                            125                    94                     75
 North Carolina                       39                    31                     79
 North Dakota                          4                     3                     75
 Ohio                                 96                    71                     74
 Oklahoma                             24                    16                     67
 Oregon                               23                    19                     83
 Pennsylvania                        117                    93                     79
 Rhode Island                          9                     4                     44
 South Carolina                       32                    24                     75
 South Dakota                          5                     4                     80
 Tennessee                            40                    36                     90
 Texas                               189                   134                     71
 Utah                                 18                    14                     78
 Vermont                               2                     2                    100
 Virginia                             40                    33                     83
 Washington                           33                    26                     79
 West Virginia                        15                    11                     73
 Wisconsin                            51                    41                     80
 Wyoming                               2                     2                    100

Source: GAO.




Page 22                                 GAO-03-924 Hospital Bioterrorism Preparedness
Appendix I: Selected Results of GAO Survey
of Hospitals Regarding Hospital Preparedness
for Bioterrorism




Table 5: Percentage of Urban Hospitals with a Written Emergency Response Plan
Addressing Bioterrorism, by State

State                                                        Percentage of hospitals
Alabama                                                                          80.9
Arizona                                                                          89.9
Arkansas                                                                        100.0
California                                                                       88.9
Colorado                                                                         89.2
Connecticut                                                                      85.7
Florida                                                                          90.4
Georgia                                                                          85.2
Illinois                                                                         81.4
Indiana                                                                          85.3
Iowa                                                                             76.9
Kansas                                                                           66.7
Kentucky                                                                         90.1
Maryland                                                                         80.8
Massachusetts                                                                    88.9
Michigan                                                                         78.0
Minnesota                                                                        68.0
Mississippi                                                                      91.8
Missouri                                                                         77.3
New Jersey                                                                       93.5
New York                                                                         74.1
North Carolina                                                                   80.0
Ohio                                                                             81.7
Oklahoma                                                                         79.6
Oregon                                                                           71.1
Pennsylvania                                                                     77.0
South Carolina                                                                   83.3
Tennessee                                                                        83.2
Texas                                                                            74.2
Utah                                                                             93.5
Virginia                                                                         73.8
Washington                                                                       84.8




Page 23                                 GAO-03-924 Hospital Bioterrorism Preparedness
Appendix I: Selected Results of GAO Survey
of Hospitals Regarding Hospital Preparedness
for Bioterrorism




 State                                                                   Percentage of hospitals
 West Virginia                                                                                   63.0
 Wisconsin                                                                                       78.0

Source: GAO.

Note: Responses were weighted to provide estimates for the universe of hospitals. Data are
presented for states that had at least 10 hospitals respond to survey and a response rate of at least
50 percent.




Page 24                                        GAO-03-924 Hospital Bioterrorism Preparedness
                                        Appendix I: Selected Results of GAO Survey
                                        of Hospitals Regarding Hospital Preparedness
                                        for Bioterrorism




Table 6: Percentage of Urban Hospitals That Reported Specifying in Emergency Response Plan to Contact the Specified
Entities during an Emergency, by State

                                                                                        Other state
                                                                             Public      and local                     Public
                        Law                                     Other        health    government        Other        private
State            enforcement    Fire    EMS       HAZMAT     hospitals     agencies       agencies laboratories       utilities
Alabama                 94.5    89.0    89.0         89.0         89.0          81.9           94.5          48.8         63.3
Arizona                100.0   100.0    94.4         81.6         94.4          94.4           83.2          74.1        81.6
Arkansas                93.7    93.7    93.7         87.4         93.7          93.7           87.4          40.4         85.6
California              94.1    92.9    96.4         89.9         86.3          97.2           85.8          45.8         70.0
Colorado                93.5    94.0    68.1         94.0         87.9         100.0           94.0          45.8         80.4
Connecticut            100.0   100.0   100.0        100.0        100.0          94.4           77.8          70.6         83.3
Florida                 95.9    97.3    94.7         95.9         91.4          93.9           97.0          58.8         73.0
Georgia                 93.7   100.0    96.5         94.5         89.8          90.9           93.5          64.1         78.6
Illinois                92.5    88.1    92.6         84.6         94.1          94.1           78.8          58.5         66.2
Indiana                 91.4    94.3    94.3         91.1         91.4          94.3           91.1          60.2         79.9
Iowa                    90.0    90.0    90.0         90.0         90.0          80.0           80.0          80.0       100.0
Kansas                 100.0   100.0   100.0        100.0         87.5         100.0          100.0          62.5         87.5
Kentucky                89.1    83.6    83.6         76.6         83.6          89.1          100.0          61.7         67.2
Maryland               100.0    95.2   100.0         90.5         81.0         100.0           95.2          57.1         85.0
Massachusetts          100.0    96.8    96.8         96.8         77.4         100.0           93.3          71.0         80.6
Michigan                92.1   100.0    88.9         89.5         92.1          97.4           92.3          62.2         81.6
Minnesota              100.0   100.0   100.0         94.1         94.1          94.1           76.5          41.2         56.3
Mississippi             91.0    91.0   100.0         70.5        100.0         100.0          100.0          67.6         70.5
Missouri                82.3    89.4    88.4         81.3         84.3          88.4           81.3          46.0         70.7
New Jersey              97.7    95.3    95.3         95.3         90.7          88.1           90.7          61.9         86.0
New York               100.0   100.0    95.1         91.8         86.1          98.5           95.6          58.9         70.1
North Carolina          95.8    95.8    91.7         83.3         87.5          87.0           91.7          47.6         82.6
Ohio                    96.4    92.7    94.5         90.9         94.4          94.5           92.7          57.7        81.5
Oklahoma                92.2    92.2    92.2         92.2        100.0         100.0           92.2          81.6         92.2
Oregon                  75.6    75.6    75.6        100.0         67.4         100.0           67.4          34.9        59.3
Pennsylvania            92.7    97.1    95.7         95.7         86.8          95.6           95.7          58.0         80.0
South Carolina         100.0    93.0   100.0         93.0        100.0          93.9          100.0          38.3         87.8
Tennessee              100.0    90.4    93.6         89.5         90.4         100.0           96.8          75.7         74.9
Texas                   90.0    90.4    90.3         88.3         80.3          90.6           86.8          56.2         76.3
Utah                   100.0   100.0    91.1        100.0         93.1         100.0           84.2          34.0         84.2
Virginia                96.1    92.1   100.0         88.2        100.0          95.9           92.1          64.9         81.3
Washington              91.0    91.0    86.5         86.5         95.3         100.0           85.9          53.3         53.3




                                        Page 25                                 GAO-03-924 Hospital Bioterrorism Preparedness
                                       Appendix I: Selected Results of GAO Survey
                                       of Hospitals Regarding Hospital Preparedness
                                       for Bioterrorism




                                                                                                Other state
                                                                                  Public         and local                            Public
                        Law                                       Other           health       government        Other               private
 State           enforcement    Fire   EMS       HAZMAT        hospitals        agencies          agencies laboratories              utilities
 West Virginia         100.0   100.0   100.0        100.0           100.0             86.3             100.0             63.7            54.9
 Wisconsin              96.8    96.8    90.3          93.5            87.5            90.0               90.6            45.2            65.6

Source: GAO.

                                       Note: Responses were weighted to provide estimates for the universe of hospitals. Data are
                                       presented for states that had at least 10 hospitals respond to survey and a response rate of at least
                                       50 percent.




                                       Page 26                                        GAO-03-924 Hospital Bioterrorism Preparedness
                                         Appendix I: Selected Results of GAO Survey
                                         of Hospitals Regarding Hospital Preparedness
                                         for Bioterrorism




Table 7: Percentage of Urban Hospitals Whose Mass Casualty Plans Address Bioterrorism and Describe How to Manage the
Specified Function, by State

                                                                                                          Obtaining
                                                                                              Obtaining additional
                                                                                              additional      other
                                                                                   Obtaining    staff for supplies
                 Decontamination     Mass     Worried       Mass        Mass       additional     surge for surge Hospital
State                  of victims   patient      well     fatality evacuation pharmaceuticals capacity capacity security
Alabama                     100.0     94.5         76.3     68.5       92.9              94.2      100.0        94.5     100.0
Arizona                      88.8    100.0         69.3     76.0       92.4              92.4      100.0        84.8      92.4
Arkansas                     87.4     93.7         85.6     66.7       93.3              93.7      100.0        93.7     100.0
California                   94.7     95.5         82.9     75.3       95.6              91.1        97.9       97.8      98.9
Colorado                    100.0    100.0         81.9     86.2       87.9              94.0        91.8      100.0     100.0
Connecticut                 100.0    100.0         88.9     66.7      100.0              88.9        94.4       94.4     100.0
Florida                      95.0     95.5         69.7     77.6       88.9              98.5        98.8      100.0     100.0
Georgia                      94.5     97.2         84.2     79.9       86.9              86.2        93.7       91.5      96.5
Illinois                     97.0     98.5         77.6     77.3       91.0              97.0        97.0       97.0     100.0
Indiana                      94.1     94.3         78.5     79.9       85.7              77.0        97.1       94.3      94.3
Iowa                        100.0    100.0         80.0    100.0       90.0             100.0      100.0       100.0     100.0
Kansas                      100.0     87.5         71.4     75.0      100.0              87.5        87.5       87.5     100.0
Kentucky                     89.1    100.0         83.6    100.0       94.5             100.0      100.0        94.5     100.0
Maryland                    100.0    100.0         95.0     95.0       94.4             100.0      100.0       100.0     100.0
Massachusetts                96.9     93.8         77.4     75.0       87.5              81.3      100.0        87.5     100.0
Michigan                     92.3     94.9         66.7     65.8       87.2              73.7        92.3       89.7      94.9
Minnesota                    76.5     88.2         52.9     52.9       64.7              94.1      100.0        94.1     100.0
Mississippi                  79.5    100.0         79.5     82.0       91.0             100.0        91.0       91.0      91.0
Missouri                     96.5     96.5         80.6     78.8       89.4              82.3        96.5       82.3      96.5
New Jersey                  100.0     93.0         65.9     75.0       90.7              97.7        93.0       95.3     100.0
New York                     91.1     98.5         77.1     65.4       92.4              80.2        97.0       92.2      98.5
North Carolina               95.8     87.5         62.5     58.3       79.2              72.7        91.7       75.0      95.8
Ohio                        100.0     96.4         75.9     81.8       94.4              83.6        96.4       92.7      98.2
Oklahoma                    100.0    100.0         90.8     91.6       88.9              91.6      100.0       100.0     100.0
Oregon                      100.0    100.0      100.0       91.9      100.0              91.9        83.7       91.9     100.0
Pennsylvania                 94.2     94.3         71.8     59.3       90.0              82.3        95.7       92.9     100.0
South Carolina              100.0    100.0         78.7     90.7       95.3             100.0      100.0       100.0     100.0
Tennessee                    93.6     96.8         79.8     86.2       96.8              90.4        93.6       93.6      92.7
Texas                        89.8     98.1         74.8     77.4       88.1              74.5        91.2       86.9      97.1
Utah                        100.0    100.0      100.0      100.0      100.0              77.2        93.1       91.1     100.0
Virginia                     91.0     91.0         82.0     75.3       91.0              87.1        96.1       95.0      95.0




                                         Page 27                                 GAO-03-924 Hospital Bioterrorism Preparedness
                                         Appendix I: Selected Results of GAO Survey
                                         of Hospitals Regarding Hospital Preparedness
                                         for Bioterrorism




                                                                                                          Obtaining
                                                                                              Obtaining additional
                                                                                              additional      other
                                                                                   Obtaining    staff for supplies
                 Decontamination     Mass     Worried       Mass        Mass       additional     surge for surge Hospital
 State                 of victims   patient      well     fatality evacuation pharmaceuticals capacity capacity security
 Washington                 100.0     86.5         73.1      73.1           91.0                  86.5         100.0          86.5        100.0
 West Virginia              100.0    100.0         68.7      86.3           86.3                  86.3         100.0          86.3        100.0
 Wisconsin                  100.0     96.9         70.0      84.4           93.8                  75.0          93.8          87.5        100.0

Source: GAO.

                                         Note: Responses were weighted to provide estimates for the universe of hospitals. Data are
                                         presented for states that had at least 10 hospitals respond to survey and a response rate of at least
                                         50 percent.




                                         Page 28                                        GAO-03-924 Hospital Bioterrorism Preparedness
Appendix I: Selected Results of GAO Survey
of Hospitals Regarding Hospital Preparedness
for Bioterrorism




Table 8: Percentage of Urban Hospitals That Had Agreements with Other Hospitals
or City, County, State, and Regional Organizations to Provide or Share Resources
in the Event of Bioterrorism, by State

State                     Hospitals            City   County       State    Regional
Alabama                        73.1            51.1     45.5        35.7         30.8
Arizona                        73.1            52.8     58.5        21.1         21.1
Arkansas                       75.6            70.8     52.7        48.6         35.4
California                     55.5            36.8     58.9        33.6         32.2
Colorado                       74.4            43.8     38.3        21.9         32.8
Connecticut                    45.0            57.9     14.3        33.3         35.3
Florida                        75.8            49.8     64.5        39.3         34.7
Georgia                        76.3            55.1     62.6        38.4         42.9
Illinois                       61.0            55.2     45.6        55.6         49.3
Indiana                        70.8            60.5     68.5        41.5         34.4
Iowa                           84.6            72.7     72.7        50.0         40.0
Kansas                         58.3            44.4     54.5        33.3         40.0
Kentucky                       76.5            58.5     67.2        14.0         34.7
Maryland                       52.4            33.3     66.7        43.8         43.8
Massachusetts                  50.0            57.1     21.9        34.4         45.5
Michigan                       73.6            53.1     70.0        40.0         57.4
Minnesota                      72.7            42.9     47.6        35.0         35.0
Mississippi                    84.8            48.2     48.2        45.9         48.2
Missouri                       70.7            54.2     39.6        27.7         39.6
New Jersey                     73.3            42.9     59.5        38.5         31.6
New York                       58.7            27.6     44.3        21.1         20.8
North Carolina                 64.5            35.5     45.2        33.3         43.3
Ohio                           82.4            68.3     71.3        45.8         46.6
Oklahoma                       92.0            83.5     83.5        69.1         64.5
Oregon                         88.2            65.6     57.9        18.4         40.5
Pennsylvania                   60.6            39.2     52.1        26.1         41.5
South Carolina                 91.1            69.6     81.6        69.7         41.0
Tennessee                      82.5            72.8     72.8        58.7         39.5
Texas                          57.2            40.5     31.5        17.1         24.2
Utah                           82.6            45.9     45.9        50.0         53.6
Virginia                       93.8            59.2     59.2        50.3         84.6
Washington                     92.4            73.1     76.5        50.7         43.6




Page 29                                 GAO-03-924 Hospital Bioterrorism Preparedness
Appendix I: Selected Results of GAO Survey
of Hospitals Regarding Hospital Preparedness
for Bioterrorism




 State                        Hospitals             City       County            State     Regional
 West Virginia                      91.4            71.6           65.4           45.7           25.9
 Wisconsin                          62.2            44.4           48.6           16.7           24.1

Source: GAO.

Note: Responses were weighted to provide estimates for the universe of hospitals. Data are
presented for states that had at least 10 hospitals respond to survey and a response rate of at least
50 percent.




Page 30                                        GAO-03-924 Hospital Bioterrorism Preparedness
                                            Appendix I: Selected Results of GAO Survey
                                            of Hospitals Regarding Hospital Preparedness
                                            for Bioterrorism




Table 9: Percentage of Urban Hospitals That Have Provided Training to Staff (Services, Courses, or Self-Learning Materials)
to Identify and Diagnose Symptoms for the Following Biological Agents, by State

 State                         Smallpox         Anthrax      Plague       Botulism         Tularemia    Hemorrhagic fever viruses
 Alabama                             88.2             92.1      79.2           71.3             62.4                           71.3
 Arizona                             73.4             78.4      73.4           73.4             68.3                           73.4
 Arkansas                            93.7             93.7      79.3           87.4             79.3                           73.0
 California                          89.2             91.0      87.4           86.5             82.8                           84.6
 Colorado                            84.7             89.8      79.6           73.0             67.9                           73.0
 Connecticut                         85.7             95.2      81.0           85.0             80.0                           70.0
 Florida                             86.2             94.3      74.2           78.2             65.7                           69.1
 Georgia                             88.5          100.0        88.5           88.5             86.2                           83.2
 Illinois                            95.2             96.4      78.5           83.7             72.7                           73.4
 Indiana                             81.6             89.8      76.7           74.3             63.9                           62.2
 Iowa                                92.3             92.3      76.9           84.6             66.7                           83.3
 Kansas                              83.3             91.7      66.7           66.7             66.7                           58.3
 Kentucky                            90.1          100.0        90.1           90.1             85.2                           80.3
 Maryland                            88.5             96.2      84.6           84.6             84.0                           80.0
 Massachusetts                       89.2             91.9      77.1           75.0             75.0                           71.4
 Michigan                            88.7             92.5      81.1           79.2             64.7                           65.4
 Minnesota                           91.7             91.7      82.6           87.0             65.2                           59.1
 Mississippi                         92.4             92.4      92.4           92.4             92.4                           82.6
 Missouri                            83.3             91.3      70.0           70.0             70.0                           67.3
 New Jersey                          97.8          100.0        95.6           95.5             86.4                           86.4
 New York                            89.3             94.6      87.8           85.0             76.3                           77.9
 North Carolina                      87.1             93.5      77.4           77.4             64.5                           58.1
 Ohio                                88.8             91.6      84.6           77.6             65.9                           67.3
 Oklahoma                            87.6             93.8      87.6           87.6             76.8                           78.3
 Oregon                              94.2             94.5      76.9           82.6             69.4                           63.6
 Pennsylvania                        87.0             91.3      82.3           82.3             74.2                           72.5
 South Carolina                      96.1             96.1      76.0           76.0             52.5                           42.7
 Tennessee                           91.0             93.7      85.5           82.0             78.6                           78.6
 Texas                               83.1             92.5      75.9           77.0             64.6                           62.5
 Utah                                85.2          100.0        85.2           85.2             85.2                           85.2
 Virginia                            85.5             85.5      85.0           78.2             64.1                           60.0
 Washington                          84.8             92.4      77.2           77.2             65.8                           69.6




                                            Page 31                                   GAO-03-924 Hospital Bioterrorism Preparedness
                            Appendix I: Selected Results of GAO Survey
                            of Hospitals Regarding Hospital Preparedness
                            for Bioterrorism




 State           Smallpox       Anthrax         Plague         Botulism        Tularemia          Hemorrhagic fever viruses
 West Virginia       90.5           100.0           90.5             78.4              78.4                                  68.9
 Wisconsin           92.5             95.0          82.5             87.5              72.5                                  72.5

Source: GAO.

                            Note: Responses were weighted to provide estimates for the universe of hospitals. Data are
                            presented for states that had at least 10 hospitals respond to survey and a response rate of at least
                            50 percent.




                            Page 32                                         GAO-03-924 Hospital Bioterrorism Preparedness
Appendix I: Selected Results of GAO Survey
of Hospitals Regarding Hospital Preparedness
for Bioterrorism




Table 10: Percentage of Urban Hospitals That Participated in Mass Casualty Drills
Related to Biological Incidents by State

State                                                        Percentage of hospitals
Alabama                                                                          54.5
Arizona                                                                          36.7
Arkansas                                                                         41.4
California                                                                       57.3
Colorado                                                                         35.8
Connecticut                                                                      47.6
Florida                                                                          58.4
Georgia                                                                          44.6
Illinois                                                                         38.3
Indiana                                                                          61.6
Iowa                                                                             53.8
Kansas                                                                           41.7
Kentucky                                                                         57.7
Maryland                                                                         38.5
Massachusetts                                                                    35.1
Michigan                                                                         43.4
Minnesota                                                                        32.0
Mississippi                                                                      65.2
Missouri                                                                         39.9
New Jersey                                                                       50.0
New York                                                                         33.6
North Carolina                                                                   45.2
Ohio                                                                             66.3
Oklahoma                                                                         51.7
Oregon                                                                           48.1
Pennsylvania                                                                     39.7
South Carolina                                                                   33.3
Tennessee                                                                        40.1
Texas                                                                            44.2
Utah                                                                             60.2
Virginia                                                                         70.9
Washington                                                                       54.3




Page 33                                 GAO-03-924 Hospital Bioterrorism Preparedness
Appendix I: Selected Results of GAO Survey
of Hospitals Regarding Hospital Preparedness
for Bioterrorism




 State                                                                   Percentage of hospitals
 West Virginia                                                                                   17.3
 Wisconsin                                                                                       48.8

Source: GAO.

Note: Responses were weighted to provide estimates for the universe of hospitals. Data are
presented for states that had at least 10 hospitals respond to survey and a response rate of at least
50 percent.




Page 34                                        GAO-03-924 Hospital Bioterrorism Preparedness
              Appendix II: Scope and Methodology
Appendix II: Scope and Methodology


              Between May and September 2002 we surveyed more than 2,000 short-
              term,1 nonfederal, general medical and surgical hospitals with emergency
              departments located in metropolitan statistical areas (MSAs).2 Survey
              hospitals were located in the 50 states and the District of Columbia.

              The survey questionnaire contained three parts. The first and second parts
              addressed emergency room functioning, and the third part addressed
              hospital preparedness for bioterrorism. We reported our survey findings
              on emergency room functioning in March 2003.3 We conducted our work
              between May 2002 and July 2003 in accordance with generally accepted
              government auditing standards.

              Of the initial universe of 2,041 hospitals that met the selection criteria,
              18 had closed by 2002 and 2 did not have emergency departments in fiscal
              year 2001, resulting in a final universe of 2,021 hospitals. We sent our
              questionnaire to these hospitals and conducted follow-up mailings and
              telephone follow-up calls to nonrespondents. We obtained responses to
              the survey from 1,489 hospitals, for an overall response rate of about 74
              percent. However, 7 of these hospitals did not return the section of the
              survey addressing emergency preparedness, leaving 1,482, for a response
              rate of about 73 percent for the questions of concern for the current
              report.4

              We analyzed the response rates by hospital size, type of ownership, and
              teaching status to assess if there was differential response among various
              categories of hospitals. The only statistically significant disproportionate
              response was from for-profit hospitals. Therefore we weighted responses
              to adjust for a lower response rate from investor-owned (for-profit)
              hospitals to provide estimates representative of the entire universe of
              2,021 hospitals in MSAs. Using the information provided by surveyed
              hospitals, we described the extent of emergency preparedness for


              1
               We excluded federal hospitals, specialty hospitals, long-term care facilities, and hospitals
              located outside the 50 states or the District of Columbia.
              2
               We focused on hospitals located in metropolitan areas designated as MSAs and Primary
              MSAs by the U.S. Census Bureau. For purposes of this report, we will refer to both types of
              areas as MSAs. In 2000, about 80 percent of the nation’s population lived in MSAs.
              3
               U.S. General Accounting Office, Hospital Emergency Departments: Crowded Conditions
              Vary among Hospitals and Communities, GAO-03-460 (Washington, D.C.: Mar. 14, 2003).
              4
               Questionnaires received after September 3, 2002, were not included in calculating our
              response rate and were excluded from our analyses.




              Page 35                                    GAO-03-924 Hospital Bioterrorism Preparedness
Appendix II: Scope and Methodology




bioterrorist incidents. We also examined the relationships between the
extent of hospital bioterrorism preparedness and size of hospital as
indicated by the number of inpatient staffed beds.

Questions in the survey focused on preparedness to respond to a
bioterrorist event. Some of the responses are applicable more broadly to
preparedness for all types of terrorist events, as well as for natural
disasters or naturally occurring disease outbreaks. However, because the
focus of this work was bioterrorism preparedness, we did not ask more
detailed questions on other types of preparedness.




Page 36                              GAO-03-924 Hospital Bioterrorism Preparedness
                  Appendix III: GAO Contact and Staff
Appendix III: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  Marcia Crosse, (202) 512-7119
GAO Contact
                  In addition to the contact named above, George Bogart, Jennifer Cohen,
Acknowledgments   Robert Copeland, Susan Lawes, Deborah Miller, and Roseanne Price made
                  key contributions to this report.




                  Page 37                               GAO-03-924 Hospital Bioterrorism Preparedness
             Related GAO Products
Related GAO Products


             Severe Acute Respiratory Syndrome: Established Infectious Disease
             Control Measures Helped Contain Spread, but a Large-Scale Resurgence
             May Pose Challenges. GAO-03-1058T. Washington, D.C.: July 30, 2003.

             Bioterrorism: Information Technology Strategy Could Strengthen
             Federal Agencies’ Abilities to Respond to Public Health Emergencies.
             GAO-03-139. Washington, D.C.: May 30, 2003.

             SARS Outbreak: Improvements to Public Health Capacity Are Needed for
             Responding to Bioterrorism and Emerging Infectious Diseases.
             GAO-03-769T. Washington, D.C.: May 7, 2003.

             Smallpox Vaccination: Implementation of National Program Faces
             Challenges. GAO-03-578. Washington, D.C.: April 30, 2003.

             Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have
             Improved Public Health Response Capacity, but Gaps Remain.
             GAO-03-654T. Washington, D.C.: April 9, 2003.

             Bioterrorism: Preparedness Varied across State and Local Jurisdictions.
             GAO-03-373. Washington, D.C.: April 7, 2003.

             Hospital Emergency Departments: Crowded Conditions Vary among
             Hospitals and Communities. GAO-03-460. Washington, D.C.:
             March 14, 2003.

             Homeland Security: New Department Could Improve Coordination but
             Transferring Control of Certain Public Health Programs Raises
             Concerns. GAO-02-954T. Washington, D.C.: July 16, 2002.

             Homeland Security: New Department Could Improve Biomedical R&D
             Coordination but May Disrupt Dual-Purpose Efforts. GAO-02-924T.
             Washington, D.C.: July 9, 2002.

             Homeland Security: New Department Could Improve Coordination but
             May Complicate Priority Setting. GAO-02-893T. Washington, D.C.:
             June 28, 2002.

             Homeland Security: New Department Could Improve Coordination but
             May Complicate Public Health Priority Setting. GAO-02-883T.
             Washington, D.C.: June 25, 2002.




             Page 38                          GAO-03-924 Hospital Bioterrorism Preparedness
           Related GAO Products




           Bioterrorism: The Centers for Disease Control and Prevention’s Role in
           Public Health Protection. GAO-02-235T. Washington, D.C.:
           November 15, 2001.

           Bioterrorism: Review of Public Health Preparedness Programs.
           GAO-02-149T. Washington, D.C.: October 10, 2001.

           Bioterrorism: Public Health and Medical Preparedness. GAO-02-141T.
           Washington, D.C.: October 9, 2001.

           Bioterrorism: Coordination and Preparedness. GAO-02-129T.
           Washington, D.C.: October 5, 2001.

           Bioterrorism: Federal Research and Preparedness Activities.
           GAO-01-915. Washington, D.C.: September 28, 2001.

           West Nile Virus Outbreak: Lessons for Public Health Preparedness.
           GAO/HEHS-00-180. Washington, D.C.: September 11, 2000.

           Combating Terrorism: Need for Comprehensive Threat and Risk
           Assessments of Chemical and Biological Attacks. GAO/NSIAD-99-163.
           Washington, D.C.: September 14, 1999.

           Combating Terrorism: Observations on Biological Terrorism and Public
           Health Initiatives. GAO/T-NSIAD-99-112. Washington, D.C.: March 16,
           1999.




(290269)
           Page 39                         GAO-03-924 Hospital Bioterrorism Preparedness
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