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Lessons Learned from the Field of Emergency Preparedness

This resource was developed by AHRQ as part of its Public Health Emergency Preparedness program, which was discontinued on June 30, 2011. Many of AHRQ's PHEP materials and activities will be supported by other Federal agencies. Notice of transfer to another agency will be posted on this site.

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Transcript of Webcast

This is the transcript of a Webcast titled Lessons Learned from the Field of Emergency Preparedness that took place on November 6, 2008.

Select to access the slide presentation (PowerPoint® file, 2 MB).

Cindy DiBiasi: Welcome, and thank you for joining us today for this Webcast, Lessons Learned from the Field of Emergency Preparedness. I would like to thank the Agency for Healthcare Research and Quality (AHRQ) for hosting this event and acknowledge Sally Phillips, the Director of AHRQ's Pubic Health Emergency Preparedness program, for making this live event possible.

AHRQ has produced a considerable number of research studies and related products, models, and tools to assist our Nation in preparing for possible mass casualty events, terrorist attacks, and other public health emergencies. It is AHRQ's hope that through this Webcast, you will learn about its evidence-based tools as well as some valuable implementation strategies for your community.

Today's session features three experienced emergency preparedness professionals: Terri Gill from the California Department of Public Health; Nancie McAnaugh from the Missouri Department of Health and Senior Services; and Christian Feller from Aultman Health Foundation, based in Canton, Ohio. Each represents different regions of the country with distinct populations, geographies, and threats. They will offer diverse perspectives on emergency planning. They will also discuss how they customized AHRQ emergency preparedness tools to address their communities' distinct needs.

From the list of registrants, it is clear that most of you are emergency preparedness practitioners representing State and local agencies, emergency responders, and hospitals. We hope that you will benefit from listening to lessons learned from your peers while implementing real world preparedness plans.

Once we hear from all three speakers, we will devote the rest of the Webcast to answering your questions. We encourage you to submit questions for our speakers by typing them into the Q&A panel. This is intended to be an interactive forum, so we encourage you to submit your questions to our speakers throughout the presentation. We will do our best to address as many of them as we can following the presentations.

Now I have the pleasure of introducing our first presenter, Terri Gill, who is the Senior Emergency Services Coordinator for the Emergency Preparedness Office at the California Department of Public Health, where she is responsible for statewide public health emergency operational response planning. She will discuss California's utilization of AHRQ's Rocky Mountain Regional Care Model for Bioterrorist Events tool as well as California's statewide surge plan. Terri, I'll turn it over to you.

Terri Gill: Thank you, Cindy. Today, I'm going be talking about establishing and operating government-authorized alternate care sites (ACSs) in California, California's Surge Standards and Guidelines Project, as well as how AHRQ's Rocky Mountain Regional Care Model for Bioterrorist Events assisted us in this endeavor. As you know, a catastrophic natural disaster will put an inordinate strain on the health care system. While California has a robust emergency management system and has built a strong collaborative network of health care services and agencies through local health departments, local emergency services agencies, hospitals, clinics, long term care facilities, and health care professionals, developing a coordinated response among these entities for a dramatic increase in patient care is challenging. To address this issue, California embarked upon the California Surge Standards and Guidelines Project. We convened a broad group of stakeholders and interested parties to develop comprehensive guidelines and standards to enable health care facilities, communities, and licensed health care professionals to address the many complex issues of health care surge capacity planning. We developed standards and guidelines that would serve as the basis for emergency planning and operations of health care facilities, providers, and communities during an unexpected emergency, which results in an increase in the demand for health care services.

One focus of the California Surge Standards and Guidelines Project was to look beyond hospitals for surge capacity. In California, a health care surge is proclaimed in a local jurisdiction when an authorized local official determines, subsequent to a significant emergency, that the health care system has been impacted, resulting in an excessive demand over capacity for health care services. To address this excess in demand, we looked at expanding beyond the hospitals, shifting patients throughout the State, and looking at other facilities. We defined alternate care sites to reflect the legal requirements in our State and the operational needs of the State. As such, a government-authorized alternate care site is a location not currently providing health care services that will be converted to enable the provision of health care services to support outpatient and inpatient care required during a surge event. Outpatient and inpatient care will vary based on resource availability and event-specific patient needs and may be structured differently than typically seen in existing facilities. These specific sites are not part of the assets of an existing facility, such as an extension of acute care hospitals, but rather contracted under the authority of the local and State government.

The Rocky Mountain Regional Care Model for Bioterrorist Events was used to identify areas to focus on to plan for surge. As a matter of fact, the Alternate Care Site Planning Team looked at this tool for a period of two days and looked at the site selection component, the staffing component, and the supply component. We had different tracks for those particular areas, and in the site selection piece, which was the primary focus of our efforts, we took that tool and modified it for California. The Rocky Mountain tool talks about a site in terms of whether it is like a hospital or is not like a hospital, and in our discussions we realized that because alternate care sites are a last resort and not necessarily affiliated with an existing health care facility, that particular model of scaling and ranking an alternate care site didn't apply to us. We changed those rankings to "present," "not present," or "can be reasonably accommodated." In the site selection piece we looked at infrastructure—things like doors, floors, climate control, layout, auxiliary space, utilities, communication, and clinical requirements. All of these infrastructure components were in the Rocky Mountain tool and could be adapted for what we needed to do in California. We prioritized those components to determine which items were critical and which could be reasonably accommodated and brought in, knowing that what services could be provided in an alternate care site were very much contingent upon the resources at the time that the alternate care site is activated. This model really helped us to develop a tool that we could use in California and which we hope can be adapted to other States in their efforts, as well.

California's definitions are based on an operational approach to surge planning. Alternate care sites, as I said, are considered a last resort established only when all of California's health resources have been depleted; when we can't move patients anywhere else in the State to receive care we would activate alternate care sites through our emergency management organizations. Due to this definition, alternate care sites are designated under the authority of a local government. These definitions recognize that all licensed health care facilities and expansions of these facilities must operate under existing and modified statutory and regulatory standards and that government-authorized alternate care sites are not governed by these statutes and regulations.

In terms of the roles and responsibilities for alternate care sites, while there is no constitutional right to health care in California, the California Emergency Services Act recognizes the role of the State and its political subdivisions to mitigate the effects of an emergency. Stemming from this authority, local governments can contract with local and private entities to establish an alternate care site in efforts to mitigate the effects of manmade or natural catastrophic disasters. These contractors receive the immunities under California's Emergency Services Act. Under the California Department of Public Health Pandemic Influenza Response Plan, local health departments are responsible for identifying and planning for the operations of government-authorized alternate care sites. Local health departments lack the expertise to operate these alternate care sites, so it is not expected that the local health department operate the alternate care site. Local health departments are responsible for bringing together the right people to identify the alternate care site and plan for their operation. Local government, on the other hand, has a responsibility to set up and operate the alternate care sites. This effort will require involvement from public and private partners in a community planning effort.

Planning for the alternate care sites was a challenge. It requires the development of an Alternate Care Site Planning Team. It requires the public and private to work together. A good portion of California's health care systems is privatized and, therefore, that presents unique challenges, so everybody needs to be at the table. You need broad participation across all stakeholder types; not only health care facilities, but your local health department, local law enforcement, everybody that has a take in receiving care in California needs to be at the table as well as in other places. Help from existing health care providers is critical; they have experience in providing emergency care, they know what to expect, and capitalizing on this experience will help you in your efforts. We took an all-hazards approach. As a matter of fact, we used AHRQ's Reopening Shuttered Hospitals to Expand Surge Capacity tool, which suggested in your planning efforts to look at a generic catastrophic event or a significant infectious agent or communicable disease as a minimum in your planning effort.

Patient care and alternate care sites will vary. The standard of care is a moving target based on what a reasonable person would do with like training and under similar circumstances. Health care delivery in an alternate care site will vary from traditional hospital care and will be dependent on available resources. We know that health care professionals are going to be in short supply when we activate our alternate care sites, and that will drive the type of care that will be available at the time. Based on local surge needs, each identified alternate care site will include some mix of the following types of patients: outpatient, inpatient, critical/acute, or support. The type of facility will be based on the type of care available for patients at the time of the ACS activation.

State alternate care site caches have been established. We actually have 420 alternative care sites in California, and the ACS cache of supplies and equipment was designed using an all-hazards approach to provide for 10 to 14 days of care for 50 patients. As a matter of fact, the Rocky Mountain Regional Care Model for Bioterrorist Events did help us determine what supplies would be available in our alternate care site cache. We also used some other sources and pulled them all together to come up with an alternate care site cache containing items in nine different groups. The caches include things such as IV fluids, bandage and wound management instruments, airway intervention and management devices, immobilization devices, patient bedding, gowns, cots and miscellaneous supplies, health care provider personal protective equipment, exam supplies, general supplies, and defibrillators and associated supplies, which is a special group that will be managed by vendors offsite. Again, we used a variety of sources to come up with our list and moved forward from the Rocky Mountain Regional Care Model for Bioterrorist Events tool as a basis.

Alternate care sites are a last resort when the health care delivery system cannot meet patient needs. Alternate care sites pose a difficult challenge. Government is often given a job that cannot be resolved in the private sector, and government has an obligation to mitigate disasters. Creativity in meeting this need is required. There are a variety of approaches being taken at the local level, including the use of shuttered hospitals, fairgrounds, tents, and mobile field hospitals. It is important to capitalize on models that have already been developed, such as the Rocky Mountain Regional Care Model for Bioterrorist Events model. Why reinvent the wheel? There are so many resources out there. Use them, modify them, and then move forward. California has planned for additional technical assistance for local government, but we are working with local government to better understand how the State can help and tools that AHRQ provides helps us to move that effort forward.

Cindy DiBiasi: Thank you, Terri. In a moment you will see a quick poll question pop up to the right of your screen. Please take a moment to fill out your response.

There will be three polls throughout this Webcast. Your responses help AHRQ understand the audience and provide suggestions for tailoring AHRQ's forums to stakeholders' needs. The results will not be shared with others.

If you are unable to respond to the polls during this event, please E-mail your answers to This first question asks, "How would you characterize the organization in which you work?" Please choose only one of the following responses: Hospital, Clinic or Health Care/Medical Treatment Facility, Home Health Care, Nursing Home, Local or State Public Health Agency, Fire, Rescue, Emergency Response, Federal Government, State Government, Community/Local Government, Military, or Other.

I would like to remind everyone again that if you have any questions for our panelists or experience any technical problems during this event, all you have to do is post a question in the Q&A panel on the right hand side of your screen. Alternatively, please call 1-866-229-3239 for assistance. Also, if you want to expand or decrease the size of any panel, such as the captioning panel, on the right hand side of your screen, click the arrow shape in the upper-left corner of that panel.

I would now like to introduce Nancie McAnaugh. Nancie is the Deputy Department Director of the Missouri Department of Health and Senior Services, where she oversees all departmental operational functions and activities throughout the State. Today she will discuss Missouri's use of the Mass Medical Care with Scarce Resources tool in the development of a 'Protocol for Allocation of Ventilators.' Nancie, please begin!

Nancie McAnaugh: Thank you Cindy. It is great to be here today, and I want to thank AHRQ for having this Webinar; it will be a great opportunity for States to learn from one another. What I want to walk you through today is some of the planning scenarios that we've been working on in the State of Missouri—sort of a picture of some of the issues that we face in our State. I want to walk you through our planning process and how we utilize the Mass Medical Care with Scarce Resources document and talk about what outcomes we have seen in our State related to utilizing the planning tool, some of the challenges we faced, and some of the things maybe AHRQ would be able to work on in the future to better help our planning efforts. As you can see by the planning scenarios, a lot of what we're working on in Missouri is what every State in the Nation is working on right now. Pandemic planning efforts are ongoing in Missouri with guidelines being developed around ventilator allocation and altering medical scopes of practice for medical professionals.

One location-specific event the State is currently planning for is a potential seismic event on the New Madrid fault line. For those of you who don't know, the New Madrid seismic zone lies within the central Mississippi Valley and extends from northeast Arkansas throughout southeast Missouri, western Tennessee/western Kentucky, to southern Illinois. Historically, this area has been the site of some of the largest earthquakes in North America. Between 1811 and 1812, four catastrophic earthquakes with magnitude estimates greater than 7.0 occurred within a three-month period. So the potential for a reoccurrence of such earthquakes and their impact today on densely populated cities in and around the seismic zone has generated a lot of interest in planning for the mass casualties that such an earthquake could cause.

This slide is just a snapshot of the Missouri health care system. We are fortunate to have a pretty robust system. Lots of FQHCs (Federally Qualified Health Centers), acute care hospitals, long-term care facilities/beds, and numerous rural health care clinics that we've tried to pull into our planning efforts. While we face many of the same issues that other States face concerning surge capacity and liability issues while planning for mass casualty events, we also face kind of a unique issue in Missouri because we have two metropolitan areas, Kansas City and St. Louis, that straddle our State borders. This complicates our planning efforts somewhat because in planning to create guidelines that could be used to implement standards in a mass casualty event, it's important for us to ensure cross-border consistency in our guidelines. In Missouri, as in every other State, we have been really focusing our efforts over the last 24 months on pandemic planning. In Missouri and every other State, surge capacity is really minimal. In a mass casualty event, it will not be possible to provide traditional hospital care and because of this, health care systems need to plan and prepare for making the necessary adjustments in current health and medical care standards to ensure the care provided results in saving as many lives as possible. This was really brought home to us last year during flu season in the State of Missouri. We had a rather heavy flu outbreak, and at one point in time in the Kansas City area, 17 hospital ERs (emergency rooms) were on diversion, which was unheard of in the State of Missouri. This is something that we are taking back and looking at to inform our further planning processes when we're thinking about surge capacity. In conducting research and developing our plan, it really became evident to the subcommittee that, while there was an absence of government guidance to address these issues, that AHRQ had published some very helpful tools for States to use when creating plans to address mass casualty events.

Now, our first group to meet was really the Health Care Systems Readiness Subcommittee. They were given the task of providing a health care planning guidance involving pandemic influenza events for hospitals and for non-hospital settings, including residential care facilities, physician's offices, federally qualified health centers, rural health clinics, private home health care services, and emergency medical services. The goal of this initial plan was to prepare health care systems to provide medical care in the event of a pandemic, as well as other large scale disasters, while maintaining other essential medical services in the community during and after that event. At the conclusion of the Subcommittee's efforts it was decided to convene a Scarce Resource Allocation Committee to address some of the issues that had been raised by our initial Health Care Systems Readiness Subcommittee. AHRQ had developed dozens of tools for planners and policymakers to use in their public health preparedness activities. Since we were focusing on mass casualty events and scarce resource allocation, the two tools listed on this slide [Mass Medical Care with Scarce Resources and Altered Standards of Care in Mass Casualty Events] were really a natural for us to use as we moved forward in the development of guidelines that could be utilized by the health care system in the State of Missouri. We really started with the assumptions that the health care system is under significant stress, that staff shortages currently exist, that the just-in-time model is the norm in the health care setting, and if you introduce a significant event into this environment, substantial interruptions to the delivery of care are really inevitable.

The Altered Standards of Care in Mass Casualty Events document that AHRQ issued was really the outgrowth of the meeting that AHRQ convened in August of 2004. The purpose of the meeting was to examine how current standards of care might need to be altered in response to a mass casually event in order to save as many lives as possible, to identify planning and guidance and tools that needed to be addressed to ensure an effective health and medical care response, and to recommend specific actions that would begin to address the needs of all planners on this critical subject. Let me tell you, that's exactly what we were looking for. We needed to know what we needed to know to develop plans that provided an effective and fair medical response to a mass casualty event. Were there key principles that professionals had agreed upon that should inform our State planning efforts for mass casualty events? And what were the critical issues we needed to consider and address in planning for the provision of health and medical care in mass casualty events? This document was really great for us to help identify areas where we were on the right tack. It was also a great motivator for us to work on what I call the "golly gees"—those moments that you suddenly determine to yourself, "why didn't we think of that?" More important, when things or questions were framed differently in a document than what we had in our planning process, did we need to change the way we were framing our questions?

I cannot stress enough how valuable the Altered Standards of Care in Mass Casualty Events guide was for our Committee; this template was really helpful in our planning process. To have some really high-level professionals come together, create this document, think through issues, raise issues, such as certification and licensure, scope of practice issues, institutional autonomy issues, documentation of care, consideration of death certificate issuance, and burial practices, and put this all together in one document that States can use in their planning efforts was incredibly helpful.

The Mass Medical Care with Scarce Resources document is something that, once it was issued, we kind of picked up and ran with it in Missouri. Due to the success our Health Care Systems Readiness Subcommittee had with the AHRQ Altered Standards of Care in Mass Casualty Events document, our Scarce Resource Allocation Committee was eager to use the Mass Medical Care with Scarce Resources Community Planning Guide. The guide really was an outgrowth of AHRQ's earlier Altered Standards of Care in Mass Casualty Events document and builds and expands on the guidance offered in that document. While the Altered Standards document was helpful in identifying issues we needed to consider as we went about our planning efforts, the Mass Medical Care with Scarce Resources Community Planning Guide actually looks at issues and challenges in mass casualty response and preparedness issues across the spectrum of health care settings and provides recommendations for planners specific to each area. Each chapter in the Mass Medical Care with Scarce Resources Community Planning Guide document identifies planning challenges and opportunities, offers information about tools that planners can utilize to overcome some of these challenges, and offers suggestions on how States might approach dealing with these issues in their planning processes. There have been so many fantastic tools issued for States to utilize in their planning efforts, it's been hard for us to keep up with them all. So to have AHRQ pull together into one document all of these really important planning templates for States has been really invaluable as we move forward with our planning process.

Even though our Scarce Resource Allocation Committee had been meeting for about a year when the Mass Medical Care with Scarce Resources Community Planning Guide was issued, it was still a useful template framework that, when brought to the Committee, informed our discussion and planning efforts concerning mass care events. It really provided a model framework for our Committee to utilize as we move forward and our discussions continue on our Ventilator Allocation Protocol in Missouri. We really encouraged local public health agencies to utilize the tool in their discussions with their local emergency planning committees. Interestingly enough, we have utilized the Mass Medical Care with Scarce Resources tool to inform discussions with representatives of the trial attorney association in the State of Missouri. We have been working for the past three years in our State to try and pass altered standards protections through the State legislature and have kind of run in to a brick wall, so to speak, over the last couple of sessions. There is a wonderful chapter in the Mass Medical Care with Scarce Resources document that talks about legal issues and liability issues, and it was a very useful piece of that tool for us to be able to sit down with representatives of the trial attorney association in our State and kind of walk them through what the issues were and why this was so important to the health care system. I do believe, because we've been able to do that, that we will be able to develop some compromise language that we will get through our general assembly next session.

A planning outcome that we have been able to develop because we have utilized these two tools, as Cindy already said and I have spoke of as well, is a Ventilator Allocation Protocol for the State of Missouri. Right now we are currently vetting it through a couple of our health care systems to really think operationally is this going to work? Is it not going to work? We think we've got a system that will work pretty well in urban areas of Missouri, not so well in rural Missouri, so we're going to go back again and relook at the tool and see how we might be able to change or reformat it so that we can develop a system for rural Missouri, as well. We've developed a statewide Emergency Medical Services Work Group specifically to work around the issue of field protocols that might need to be changed for transport in a pandemic. More importantly is for us to work on a statewide mutual aid agreement for our EMS system. In the State of Missouri, we have fire-based EMS, but they are a very small piece of our EMS system. The majority of our ambulance systems are private or hospital-based or governmental ambulance districts. Our fire system has had a great mutual aid system for a long time, and we believe by the end of this year we will have a document that extends that statewide, and we're really excited about that.

The Cross-Departmental Statute and Regulations Work Group; this is a workgroup we actually started before the Mass Medical Care with Scarce Resources document came out, but has been informed by some of the issues raised by that document as well. The Missouri Department of Health and Senior Services regulates hospitals and home health centers, hospices, and regional dialysis centers. We have partnered with our Department of Mental Health, which oversees our ICFMRs (Intermediate Care Facility for People With Mental Retardation), as well as our rehabilitation centers in the State, and the Department of Social Services, which is our Medicaid Agency, to pre-identify State regulations that the governor would need to waive by executive order before we have a mass casualty care event happen. We felt it was critical that we went through now and scrubbed our regulations and our statutes to figure out what we're going to waive, what is the bottom line, we definitely can't waive this, what are our gray areas, and what in State statute can we modify should we have a mass casualty event. Pandemic grief training for managers and supervisors is really something that has grown out of discussions about mental health issues that the Mass Medical Care with Scarce Resources document brought up to us. We came to the realization that, as a State government, we don't have anything currently in place to help our managers and supervisors deal with grief issues they might be facing in a pandemic, and we don't have any just-in-time training for them right now on how they should help their frontline employees work through their grief issues should we have a severe pandemic happen in the U.S., as well. The Department of Mental Health will have that training available for State agencies early next calendar year.

The last thing I want to talk about is the creation of a statewide Ethics Consortium. We are currently in the process of finalizing a contract with the Center for Health Ethics at the University of Columbia. One of the things we asked them to do is pull together from all the bioethics groups in the State of Missouri a consortium that we can bring together, not just to talk about this whole greatest good for the greatest number, which we're basing our State plans on, but really digging down deeper into some of the ethical issues we're going to face in mass casualty events in Missouri. They will be pulling that Consortium together within the next year. The other issue they'll be helping us work through is we need to identify, in rural parts of the State, medical experts that can help us with regional triage teams since we won't have triage officers or triage teams, necessarily, at our small rural hospitals. Looking at developing a regional model of triage and then having a medical expert who could be attached to that regional triage team to help inform the process should those groups be called together in a mass casualty event.

Some of the challenges, I mentioned one already, are transferring outcomes created with tools to rural Missouri settings. A lot of times, folks in the cities forget that rural areas are different than metropolitan areas, and the planning does need to look different in those parts of the State. Another challenge was getting buy-in from the non-public health State partners on the tools. We have worked with the Department of Public Safety and some of the other emergency response agencies within our State government on the Mass Medical Care with Scarce Resources document because it is I believe such an important tool to be utilizing, and I think our Department of Public Safety sees the importance of working through some of the processes and some of the planning efforts that are in that tool for some of the response activities that they would be doing, as well. I think that's been very helpful to do.

The one thing I wish we could figure out, and the Institute of Medicine has tried to do it and everybody talks about this all the time, but there is an incredible lack of public awareness regarding the limitation of the health care system. Even having this conversation with the general assembly in the State of Missouri, they just cannot seem to fathom that, should something happen, you cannot wander in to an ER or a physician's office or hospital and expect to get the same level of care, if any care, should we have a mass casualty event happen. We have pulled some public information officers together in a couple of departments to have this conversation. We need to think through how we craft a message that resonates with the general public because so far we just have not been able to do it. The other challenge that we face is the whole concept of pediatric issues when you start talking about scarce resource allocation. Our group has been struggling with the fact that there's no evidence-based tool to utilize for ventilator allocation with children. I know for the American Academy of Pediatrics this is a question one of their Disaster Readiness Subcommittees is looking at right now, but it has sort of been a stumbling block. It's a huge gap that exists currently in our Ventilation Allocation Protocol Plan in the State of Missouri.

I wanted to provide you with a brief overview of how we've used some of AHRQ's tools and again, I appreciate being here today, and I will turn it back over to you Cindy.

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