Public Health Emergency Preparedness
This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.
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5. Measures of Preparedness
Understanding the degree to which a region is prepared for a bioterrorist
event is important to understanding regional surge capacity needs.
This chapter defines a specific set of measures for preparedness based
on data that is currently collected. As part of the RMBT Working Group
collaboration, data collection resources were identified that were
available in the six-State region and that provided information about
the medical resource capacity of the region. Other measures of preparedness
may not only address resource capacity but may also include measures
for timeliness of response and effectiveness of the incident command
system. As a surge capacity study, the measures of bioterrorism preparedness
focus on identifying the gaps between resource capacity and resource
After the RMBT Working Group identified regional medical resource capacity,
as outlined in Chapter 3, Profile of Regional Medical Resources,
the next step to defining measures of preparedness was to determine medical
resource need. Two approaches were used to identify resource need. One
was through HRSA surge
capacity benchmarks, and the second was to develop a benchmark through
the staffing, supply, and equipment templates for a 50-bed unit developed
by the Department of Defense7 and refined through input from the RMBT
Working Group in Table 7.
Based on these benchmarks, four resource areas for bioterrorism preparedness
measures have been developed:
- Hospital Beds: Current resources based on NDMS available bed
data, need based on HRSA benchmark of 500 beds necessary per 1 million
- Medical Staffing: Current resources based on HRSA health workforce
profiles, need based on HRSA benchmark of 500 beds necessary per 1 million
population combined with the staffing model for a 50 bed alternative
care site described in Table 7.
- Equipment: Current resources based on HRSA State hospital
preparedness surveys, need based on HRSA benchmarks.
- Infrastructure: Current resources based on HRSA hospital preparedness
surveys, need based on HRSA benchmarks.
7. Skidmore S, Wall W, Church J. Modular Emergency Medical System Concept of Operation for the Acute Care Center: Mass Casualty Strategy for a Biological Terror Incident, May 2003.
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Current available regional hospital bed capacity was provided by the
National Disaster Medical System (NDMS)8. NDMS collects bi-weekly hospital
bed availability data for hospital members, which is the actual number
of beds available on any given day in the region. The NDMS agencies (DoD,
VA, FEMA, HHS) have established voluntary partnerships between NDMS and
civilian hospitals through a Memorandum of Understanding (MOU). One of
the responsibilities of the participating hospitals is to provide bed
availability information to the local NDMS Federal Coordinating Center
The NDMS has been tracking available hospital beds since January 2003.
NDMS partners with approximately 2,000 non-federal hospitals concentrated
in major metropolitan areas located in 65 FCCs with 82 reception sites
(Appendix C). In Federal Region VIII, NDMS is tracking open beds in the
Colorado Front Range (Greeley, Colorado Springs, Pueblo, Fort Collins,
Boulder, and Denver) and Utah's Salt Lake City metro area. The
FCC calls the hospitals periodically to obtain number of open beds for
medical/surgery, critical care, psychiatric, pediatrics, and burns. This
data was provided to the RMBT Working Group to determine current available
hospital bed resource capacity.
Hospital bed resource need was based on the benchmarks defined by HRSA.
In 2003, under the Bioterrorism Hospital Preparedness Program, HRSA provided
regional surge capacity standards to guide regional planners. One of
the standards or benchmarks was that there should be 500 surge capacity
beds per 1 million population for acutely ill patients requiring hospitalization
from a bioterrorist event. This 500 beds per million-population HRSA
benchmark was used as a basis to define need in this study. In addition,
bed need was assessed using a higher benchmark of 750 beds per million
based on Working Group member suggestions that HRSA may increase this
benchmark in the future.
In Region VIII, both Colorado and Utah have Federal Coordinating Centers
for the National Disaster Medical Response System (NDMS). Figure 22 describes
available beds over time for a 3-month period for the Colorado Front
Range. Figure 23 describes available beds over time for a 6-month period
for the Salt Lake City area in Utah. The average number of available
beds in Colorado was 663 and in Utah was 406 for the respective time
Figure 24 indicates that the Colorado Front Range region would need to
add between 343 and 1,012 beds for the 500 bed benchmark, depending upon
how many beds they could vacate for elective conditions or less acute patients
over time. For the 750 bed per million population benchmark, the Colorado
Front Range region would need to add from 1,181 to 1,850 beds in the event
of a bioterrorist attack. This range indicates how sensitive the measure
is to the established benchmark.
Figure 25 indicates that the Utah Salt Lake City region would need to add
1, 269 beds based on the HRSA 500 bed per million population benchmark.
Utah does not ask hospitals to provide maximum number of beds that can
be vacated in 48 hours, and therefore cannot provide a range as reflected
in the Colorado Front Range. For the 750 bed per million population benchmark,
it is estimated that the Salt Lake City region would need to add 2,107
beds in the event of a bioterrorist attack.
8. The NDMS is a cooperative asset-sharing program among Federal government agencies, State, and local governments, and private businesses and civilian volunteers to ensure resources are available to provide medical services following a disaster that overwhelms the local health care resources. The NDMS is a federally coordinated system that augments the Nation's emergency medical response capability. The overall purpose of the NDMS is to establish a single, integrated national medical response capability for assisting state and local authorities in dealing with the medical and health effects of major peacetime disasters and providing support to the military and Veterans Health Administration medical systems in caring for casualties evacuated back to the United States from overseas armed conflicts.
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Current regional medical staffing resources were obtained from HRSA
State Health Workforce Profiles for each of the six States in Region
VIII (see Section 3.2).
Appendix F describes estimated needs for staffing
alternative care sites based on the DoD9 Concept of
Operations for the Acute
Care Center staffing requirements for a 50-bed alternative care site
(as outlined in Table 7) and the HRSA benchmark
of 500 beds per million population. The requirements for a 50-bed unit
were multiplied by 10
to obtain an estimate for the staffing necessary for 500 beds. It was
assumed that there are 14 12-hour shifts per week and each professional
would work 3 shifts per week. The number of shifts in a week (14) was
multiplied by the staffing estimate for 500 beds per million population
for each profession. It is estimated that it will require 14,777 staff
to operate and support the 4,663 alternative care site beds needed in
Region VIII based on the HRSA benchmark of 500 beds per million population.
Of these 14,777 staff, 464 are physicians, 933 are registered nurses,
and 1,865 are LPNs.
The 14,777 number could be less based on the beds available and that
are currently staffed as described in the section above.
Since available bed capacity is not available for all States and all
regions of each
State it is currently not possible to know to what extent this bed availability
could offset alternative care site need for the six-State region.
Consideration was given to whether there is an excess/under supply of
medical staff in the region. Some States and regions could have an excess
supply of medical staff relative to current demand and other states and
regions could have an under supply of personnel. This excess/under supply
can also vary by type of personnel. Therefore, the next step was to determine
a baseline for whether each state is meeting current demands for medical
staffing. The national average of staffing levels per 100,000 population
was the best estimate available at this time. This measure has its limitations;
because some States may have a healthier population than others, there
may be State regulatory requirements that impact State staffing levels,
and studies have shown that medical practice behavior can vary by region.
Table 8 contains the expected staffing needs
for alternative care sites ("ACS Need" in the table) in Region
VIII, based on State population and current medical labor needs/surplus.
Since HRSA data was
used to determine current capacity, only those professions described
in the HRSA Workforce profile are included in this table. For instance,
secretaries and housekeeping personnel are not included in Table
are included in Appendix F. Excess capacity
was calculated by subtracting the U.S. average per 100,000 population
profession estimate from the
State per 100,000 population profession estimate (go to the section in
Chapter 3 on Medical Staffing Resources). Staff need minus excess capacity
results in the net need. On the "Net
need/Surplus" line, negative numbers signify a surplus, while positive
numbers signify a shortage.
The following nine figures (26-34) depict the
net need or surplus for each profession in Region VIII. Based on the
HRSA benchmarks, all States
in this region may need additional physicians (Figure 26). Region VIII
as a whole is estimated to need an additional 1,971 physicians to address
a surge based on the HRSA recommendation. The majority of this need is
based on this region having an under supply of physicians, particularly
Figures 27 and 28 indicate
that there is a surplus supply of physician assistants and nurse practitioners
in the region, compared to the national
average. During a surge event there may be enough people currently in
these professions to address surge need. For States such as Utah, North
Dakota, and Wyoming, other States in the region could potentially supplement
their limited needs.
Figures 29 and 30 indicate
that the region as a whole would need 1,240 additional RNs and 6,690
LPNs to address a surge. There is wide variation
between the States and their current supply of RNs and LPNs. For instance,
Utah has a great need for RNs to address current demands, while North
Dakota and South Dakota have a surplus supply of RNs that could help
offset this regional need. For LPNs, Colorado and Utah lead all States
in need, while North Dakota has a surplus of LPNs when compared to the
national average. The majority of the LPN need is based on a current
need, where there is a regional excess demand for this profession.
Figures 31-34 depict additional staff shortage
or surplus for each of the supplemental health professions: respiratory
therapists, social workers,
clinical lab staff, and nurse assistants. This region will need an additional
658 respiratory therapists, 923 lab staff, and 6,199 nurse assistants
to address a regional surge. For respiratory therapists, only North Dakota
has a surplus based on the national average, and South Dakota is expected
to be able to meet its surge needs based on the HRSA benchmarks. Utah
has a significant need for respiratory therapists because it already
has a major shortage based on the national average. Colorado has a substantial
need for clinical lab staff, while Utah may have an oversupply. The majority
of the need for nurse assistants is based on a current environment of
an excess demand to meet current medical needs. For social workers, the
region has a large surplus for all States compared to the national average.
9. Skidmore S, Wall W, Church J. Modular Emergency Medical System Concept of Operation for the Acute Care Center: Mass Casualty Strategy for a Biological Terror Incident, May 2003.
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Current regional medical equipment resources are difficult to assess,
particularly for a multi-state region. It was expected that the HRSA
Hospital Preparedness Surveys would provide information describing the
number of ventilators, personal protective equipment (PPEs) and other
resources. The data from the hospital surveys from the 6 states was
evaluated to determine whether these questions were asked and answered
by the region's hospitals.
In developing measures of preparedness, equipment need was determined
using the HRSA benchmarks. There is no HRSA benchmark for ventilator
need. For PPE, the benchmark is 250 per million population in an urban
area and 125 PPE per million population in a rural area.
Figure 35 displays the additional PPE figures that would be necessary
in our region to meet the HRSA benchmarks. Urban areas would need 1,674
and rural areas would need 329 for a total of 2,003 additional PPE necessary
to address the HRSA guidance. The difficulty with this need measure is
that it is unclear what types of PPE are necessary in this number. Our
region's HRSA Hospital Surveys only assess whether each hospital
had PPE; specific counts were not requested by most states and when this
information was requested it was not reliable. In order to assess regional
preparedness for equipment it is necessary for hospitals to accurately
assess their PPE counts and types and for HRSA or other groups to provide
benchmarks on ventilator and specific PPE needs.
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Infrastructure needs related to bioterrorism preparedness could range
from basic facility functions, such as heating and ventilation and water
supply, to parking capacity. For the purposes of this study we focused
on infrastructure needs that are directly related to a bioterrorist event
and for which HRSA has developed benchmarks. These include adequate decontamination
systems and negative pressure and/or HEPA-filtered isolation facilities.
It was hoped that the HRSA Hospital Preparedness Surveys from the six-State
region would provide information on the hospital's current infrastructure
related to decontamination and negative pressure/isolation capabilities.
The HRSA benchmarks for infrastructure are:
- Adequate portable or fixed decontamination systems for 500 patients
per million population.
- At least one negative pressure, HEPA filtered isolation facility
per health system able to support 10 patients at a time.
Based on the HRSA benchmark, 4,664 patients would require adequate decontamination
for a surge in this region (Figure 36). The
HRSA hospital surveys asked if facilities had decontamination capability;
they did not address how
many patients each hospital with capability could handle. Roughly one
third of hospitals in three states that addressed this issue had this
capability (Figure 19). Even if we assume that this is representative
of the region, it is still unclear exactly how many patients could be
handled by these systems. The hospitals may need to be questioned as
to the number of patients they are able to decontaminate in a 24-hour
period for this measure to be developed further to assess need using
the HRSA guidance.
To measure current capacity of isolation beds in our region,
we calculated a total of 828 isolation beds for the four states in the
region (Figure 21) who asked the question on the HRSA hospital
surveys. To begin to address the HRSA benchmark need for at least one
negative pressure, HEPA filtered isolation facility per health system
able to support 10 patients at a time, we calculated the approximate
number of isolation beds per hospital in Table 9. We were not able to
access individual level data for each hospital, and therefore made an
assumption by dividing total number of isolation beds by total number
of hospitals responding to obtain an average number of isolation beds
per hospital estimate.
The region as a whole averages 2.7 isolation beds
per hospital. It is probable that most of the isolation beds counted
in the surveys are in urban facilities and therefore it hard to assume
an "average per hospital," especially in our very rural region
of the country. In addition, the HRSA benchmark is unclear as to how
many isolation beds are needed, the guidance calls for one facility per
health system to support 10 patients. Further clarification of a health
system is necessary in order to accurately measure our region's
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