Hospital Preparedness: Most Urban Hospitals Have Emergency Plans 
but Lack Certain Capacities for Bioterrorism Response (06-AUG-03,
GAO-03-924).							 
                                                                 
In the event of a large-scale infectious disease outbreak, as	 
could be seen with a bioterrorist attack, hospitals and their	 
emergency departments would be on the front line. Federal, state,
and local officials are concerned, however, that hospitals may	 
not have the capacity to accept and treat a sudden, large	 
increase in the number of patients, as might be seen in a	 
bioterrorist attack. In the Public Health Improvement Act that	 
was passed in 2000, Congress directed GAO to examine preparedness
for a bioterrorist attack. In this report GAO provides		 
information on the extent of bioterrorism preparedness among	 
hospitals in urban areas in the United States. To conduct this	 
work, GAO surveyed over 2,000 urban hospitals and about 73	 
percent provided responses addressing emergency preparedness. The
survey collected information on hospital preparedness for	 
bioterrorism, such as data on planning activities, staff	 
training, and capacity for response.				 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-03-924 					        
    ACCNO:   A07875						        
  TITLE:     Hospital Preparedness: Most Urban Hospitals Have	      
Emergency Plans but Lack Certain Capacities for Bioterrorism	 
Response							 
     DATE:   08/06/2003 
  SUBJECT:   Biological warfare 				 
	     Emergency preparedness				 
	     Hospital planning					 
	     Infectious diseases				 
	     Hospitals						 
	     Emergency medical services 			 
	     Surveys						 
	     National preparedness				 
	     Counterterrorism					 

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GAO-03-924

Report to Congressional Committees

United States General Accounting Office

GAO

August 2003 HOSPITAL PREPAREDNESS

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

GAO- 03- 924

While most urban hospitals across the country reported participating in
basic planning and coordination activities for bioterrorism response, they
did not have the medical equipment to handle the number of patients that
would be likely to result from a bioterrorist incident. Four out of five
hospitals reported having a written emergency response plan addressing
bioterrorism, but many plans omitted some key contacts, such as other

laboratories. Almost all hospitals reported participating in a local,
state, or regional interagency disaster preparedness committee. In
addition, most hospitals reported having provided at least some training
to their personnel on identification and diagnosis of disease caused by
biological agents considered likely to be used in a bioterrorist attack,
such as anthrax or botulism. In contrast, fewer than half of hospitals
have conducted drills or exercises simulating response to a bioterrorist
incident. Hospitals also reported that they lacked the medical equipment
necessary for a large influx of patients. For example, if a large number
of patients with severe respiratory problems associated with anthrax or
botulism were to arrive at a hospital, a comparable number of ventilators
would be required to treat them. Yet half of hospitals reported having
fewer than six ventilators per 100 staffed beds. In general, larger
hospitals reported more planning and training activities than smaller
hospitals.

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

Urban Hospitals with Ventilator Capabilities, per 100 Staffed Beds
Ventilators Percentage of hospitals

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. In the event of a large- scale infectious
disease outbreak, as could be seen with a bioterrorist attack, hospitals
and their

emergency departments would be on the front line. Federal, state, and
local officials are concerned, however, that hospitals may not have the
capacity to accept and treat a sudden, large increase in the number of
patients, as might be seen in a bioterrorist attack. In the Public Health
Improvement Act that was passed in 2000, Congress

directed GAO to examine preparedness for a bioterrorist attack. In this
report GAO provides information on the extent of bioterrorism preparedness
among

hospitals in urban areas in the United States. To conduct this work, GAO
surveyed over 2, 000 urban

hospitals and about 73 percent provided responses addressing emergency
preparedness. The survey collected information on hospital preparedness
for bioterrorism, such as data on

planning activities, staff training, and capacity for response. 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. Highlights of GAO- 03- 924, a
report to the

Senate Committee on Health, Education, Labor, and Pensions; the Senate and
House Committees on Appropriations; and the House Committee on Energy and

Commerce

August 2003

HOSPITAL PREPAREDNESS

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

Page i GAO- 03- 924 Hospital Bioterrorism Preparedness 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 Contents

Page ii 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 iii 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

This is a work of the U. S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. However, because this
work may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this material
separately.

Page 1 GAO- 03- 924 Hospital Bioterrorism Preparedness

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, S: 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.

United States General Accounting Office Washington, DC 20548

Page 2 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 ventilators 6 ). 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
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. Results in Brief

Page 3 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 require
for responding to a large- scale bioterrorist attack are far greater than
those needed for everyday performance. The specific equipment, supplies,
and facilities needed could vary depending upon what type of attack
occurred, but many scenarios anticipate that the demand for health care
could quickly outstrip the ability of hospitals to respond. For

example, the TOPOFF 2000 exercise 7 testing terrorism preparedness
included a bioterrorism scenario of an attack using pneumonic plague 8
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. Background

Page 4 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 5 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 6 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 7 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 8 GAO- 03- 924 Hospital Bioterrorism Preparedness

Most hospitals in urban areas across the country reported participating in
basic planning and coordination activities for bioterrorism response.
Although most hospitals reported providing at least some training to their
personnel on identification and diagnosis of disease caused by biological
agents considered likely to be used in a bioterrorist attack, only about
half report they have conducted drills or exercises simulating response to
a bioterrorist incident. Further, few reported having acquired the medical
equipment to handle the large increase in the number of patients that
would be likely to result from a bioterrorist incident.

Our survey showed that hospitals have engaged in a variety of planning and
coordination activities, with most having prepared an emergency response
plan addressing bioterrorism; participated in a local, state, or

regional interagency disaster preparedness committee; and made agreements
with at least one other organization to share personnel or equipment in
the event of a bioterrorist or other mass casualty incident.

Four out of five hospitals reported having a written emergency response
plan that specifically addresses bioterrorism (see fig. 1). Hospitals that
had a plan were on average around 15 percent larger than those that did
not in terms of number of staffed beds. 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.
Hospitals Reported

Planning for Bioterrorism Response but Do Not Have Certain Medical
Capacities to Handle a

Large Increase in Patient Load

Most Hospitals Have Emergency Response Plans Addressing Bioterrorism and
Are Participating in Local, State, or Regional Planning and Coordination
Activities

Page 9 GAO- 03- 924 Hospital Bioterrorism Preparedness

Figure 1: Percentage of Urban Hospitals with a Written Emergency Response
Plan Addressing 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.

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

81% 18%

1%

Have a plan Developing a plan

Not developing a plan Source: GAO.

Page 10 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

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.

57.1 75.8

89.3 90.7

90.8 93.4

94.2 94.6

94.7

Other laboratories Public or private utilities

Other hospitals Other state and local government agencies

HAZMAT EMS

Fire Law enforcement Public health agencies

Source: GAO.

020 40 60 80100 Percentage of hospitals

Page 11 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 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.

Source: GAO. 94.8

96.1 76.8

76.7 90.5 87.3

95.9 92.8

98.2

020 40 6080100 Decontamination of victims

Mass patient management Worried well management

Mass fatality management Mass evacuation Obtaining additional
pharmaceuticals

for surge capacity Obtaining additional staff

for surge capacity Obtaining additional other supplies

for surge capacity Hospital security

Percentage of hospitals

Page 12 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 13 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.

Approximately 7 out of 10 hospitals reported that their staff had received
training (services, courses, or self- learning materials) for identifying
and diagnosing illness caused by all six biological agents that CDC has
stated

would be most likely to be used in a bioterrorist incident (see fig. 5).
Hospitals that reported training activities for all of the biological
agents were on average around 15 percent larger than hospitals that did
not. A greater percentage of hospitals reported that staff had received
training for anthrax or smallpox (around 90 percent or more) than for
plague or Staff Training on Biological

Agents Was Reported to Be Widespread, While Hospital Participation in
Drills Was Less Common

Page 14 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 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.

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

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

Insufficient Medical Equipment to Handle a Large Increase in Patients

93.0 80.9

80.8 71.8

71.2 87.9 Smallpox Anthrax

Plague Botulism

Tularemia Hemorrhagic

fever viruses Percentage of hospitals

Source: GAO.

0 20 40 60 80 100

Page 15 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 100 a 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 16 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,
hospitals across the nation have been working to increase their
preparedness for responding to such events. The staff and equipment that
hospitals would require to respond to a bioterrorist attack with mass
casualties are far greater than what are needed for everyday performance.
Meeting those needs fully could be extremely difficult because
bioterrorism preparedness is expensive and hospitals are reluctant to
create capacity that is not needed on a routine basis and may never be
used. In addition, along with a hospital*s ability to meet the routine
needs

of the community, needs for additional capacity for responding to
bioterrorism emergencies must be balanced with the need to be prepared for
all types of emergencies. Hospital officials have recognized that their
facilities are an essential component of our nation*s bioterrorism
preparedness and have begun planning and training efforts to increase
their response capacity. Most hospitals, however, still lack equipment,
medical stockpiles, and quarantine and isolation facilities for even a
smallscale 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. Concluding

Observations

Page 17 GAO- 03- 924 Hospital Bioterrorism Preparedness

Representatives from the American Hospital Association provided oral
comments on a draft of this report. The officials generally agreed with
our findings and stated that this was a good and useful report providing
helpful information on hospital preparedness. They commended us for the
high response rate to the survey, stating that this provided a more
comprehensive picture of hospital activities than was available elsewhere.
The officials suggested that the report make greater reference to the lack
of specific benchmarks for hospitals to use in planning, provide
additional

context on the range of possible events that hospitals must consider in
their planning, and refer readers more specifically to prior GAO
recommendations on bioterrorism preparedness. We have added additional
material to clarify these points. The officials also provided technical
remarks, which we have incorporated where appropriate.

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

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

Marcia Crosse Acting Director, Health Care* Public

Health and Science Issues Comments from the

American Hospital Association

Page 18 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

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

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. Appendix I: Selected Results of GAO Survey

of Hospitals Regarding Hospital Preparedness for Bioterrorism

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

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 Number of staffed beds a 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.

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

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

State Number of

hospitals that were sent surveys

Number of hospitals that responded

to survey Percentage of

hospitals that 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

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

State Number of

hospitals that were sent surveys

Number of hospitals that responded

to survey Percentage of

hospitals that 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.

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

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

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

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.

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

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

State Law enforcement Fire EMS HAZMAT Other

hospitals Public

health agencies

Other state and local government

agencies Other laboratories

Public private 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

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

State Law enforcement Fire EMS HAZMAT Other

hospitals Public

health agencies

Other state and local government

agencies Other laboratories

Public private 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.

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

State Decontamination of victims Mass

patient Worried well Mass

fatality Mass evacuation

Obtaining additional pharmaceuticals

Obtaining additional

staff for surge capacity

Obtaining additional

other supplies for surge

capacity Hospital 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

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

State Decontamination of victims Mass

patient Worried well Mass

fatality Mass evacuation

Obtaining additional pharmaceuticals

Obtaining additional

staff for surge capacity

Obtaining additional

other supplies for surge

capacity Hospital 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.

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

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

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

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.

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

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

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

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.

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

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

Appendix I: Selected Results of GAO Survey of Hospitals Regarding Hospital
Preparedness for Bioterrorism Page 34 GAO- 03- 924 Hospital Bioterrorism
Preparedness

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.

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

Between May and September 2002 we surveyed more than 2,000 shortterm, 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. Appendix II: Scope and
Methodology

Appendix II: Scope and Methodology Page 36 GAO- 03- 924 Hospital
Bioterrorism Preparedness

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.

Appendix III: GAO Contact and Staff Acknowledgments

Page 37 GAO- 03- 924 Hospital Bioterrorism Preparedness

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

Acknowledgments GAO Contact Acknowledgments

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

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. Related GAO Products

Related GAO Products Page 39 GAO- 03- 924 Hospital Bioterrorism
Preparedness

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)

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