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Rocky Mountain Regional Care Model for Bioterrorist Event

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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3. Profile of Regional Medical Resources

As a medical surge capacity study, it was necessary to identify the current regional medical resources (medical care facilities, infrastructure needs, hospital beds, staffing and equipment/supplies) available for responding to a bioterrorist event. Through data from the Health Resources and Services Administration (HRSA) State hospital preparedness surveys and State health workforce profiles and from the American Hospital Association (AHA) and State professional associations, the Rocky Mountain Regional Care Model for Bioterrorist Events (RMBT) Working Group developed a six-State regional profile of medical resources in Federal Region VIII. The identification of current regional resources (current capacity) is necessary in order to determine the gaps in regional preparedness as will be demonstrated in Chapter 5, Measures of Preparedness.

Many individual States, counties and health care facilities collect health data, and this information can be pooled to develop a baseline regional profile of surge capacity resources. Combining this data provides a unique challenge to ensure that medical resource estimates are not replicated across State lines (e.g. a nurse licensed in two States counted as a resource by both). This chapter profiles Region VIII's medical resources as follows:

  • Medical Care Facilities: Number, type, location, and total physical beds of hospitals in region.
  • Medical Staffing Resources: Active/inactive status, in-State/out-of-State residency, primary and secondary medical staffing resources.
  • Hospital Preparedness: Regional HRSA Hospital Preparedness Survey Summary—infrastructure needs, equipment and supplies.

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Medical Care Facilities

The following is a description of the current hospital resources in the region: number of hospitals, location, and total physical number of beds. Figure 2 indicates that Region VIII has approximately 330 medical care facilities where 277 are community hospitals.

Not all medical care facilities identified by the AHA will be available or applicable to use in a surge event. The RMBT Working Group decided that community hospitals would more likely be available to assist with surge capacity needs than the other types of hospitals. For example, military or Veteran's Administration (VA) hospitals may not participate in a region's response efforts, based upon other obligations present at the time of the event. Mental health hospitals are also not an alternative resource for surge needs since the population they serve are not readily transferable. While TB hospitals are included in the "All Hospitals" count and would be applicable to a bioterrorist surge event, we have found that there are no actual TB hospitals in Federal Region VIII.

Figure 3 is a map of the locations of community hospitals in Federal Region VIII. This map is useful in assisting planners and responders in identifying the hospitals that may be in close proximity to an area that has been exposed to a bioterrorist event.

The total physical number of community hospital beds in the region is described in Figure 4. Although many hospitals are currently operating at capacity, it is important to have an estimate of total beds that could be made available if a bioterrorist event were to occur. Some patients may be able to be discharged and surgeries and procedures postponed.

Forty-six percent of the beds in the region are located in non-metropolitan areas compared with 21 percent nationwide. Almost half of the region's beds are located in Colorado and Utah, yet these States represent 70 percent of the region's population (Table 2).

Figure 5 indicates that the region as a whole currently has 3,557 hospital beds per million population, which is similar to the US average of 3,576 beds per million population. There is great variation in bed supply within the region, however, with beds that are scattered in the rural areas of the most rural States (Montana, North Dakota, South Dakota, Wyoming). Figure 5 is deceiving in that it is based on per million population so that the States with less than 1 million population (Montana, North Dakota, South Dakota, Wyoming) appear to have a surplus of beds.

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Medical Staffing Resources

Current regional medical staffing resource capacity is described in this section. It is important to profile these resources in order to understand differences between the States and the national average. Some States in the region may have more medical personnel that can be transferred to a different State to enhance capacity during a surge. The medical personnel staffing resources described include:

  • Physicians.
  • Physician assistants.
  • Nurse practitioners.
  • Registered nurses.
  • Licensed practical nurses.
  • Certified nursing assistants.
  • Respiratory therapists.
  • Social workers.
  • Secondary medical staff: dentists, podiatrists, and pharmacists.

This information was obtained from the HRSA State Health Workforce Profiles for each of the six States in Region VIII. Tables D1 and D2 in Appendix D provide detailed estimates of provider numbers for each of the above professions.

There are various approaches to identifying medical personnel resources. The challenge is ensuring that each State defines available and certified staff in the same way and that staff are not counted twice (dually State licensed). Therefore, Tables D3 and D4 in Appendix D describe the degree to which medical staff are dually licensed, although the State they are licensed in is not available.

For instance, 24 percent of the physicians licensed in Colorado are licensed in another State. These physicians may be licensed in another State located in Region VIII or a State outside of Region VIII. For the region as a whole, 25 percent of the physicians are licensed in another State, ranging from as high as 60 percent in Wyoming to as low as 24 percent in Colorado. Physicians are more likely to be dually licensed than any other medical profession. For instance, 3 percent of the physician assistants and 6 percent of the dentists are licensed out of State. Therefore, State licensing data will significantly overestimate the regional medical staffing resources available to address meeting surge needs.

The graphs in the attached figures describe the staffing resources available in the region compared to the U.S. average. The HRSA State Health Workforce Profiles for each of the six States in Region VIII provided the data used to create the graphs in Figure 6 and Figures 8-13. The data graphed in Figure 7 were obtained from the AHA Physician Characteristics and Distribution in the US, 2000-2001. If the State and/or region is less than the national average, then the State/region is considered to have a shortfall in staffing resources to meet current need. If the State and/or region is greater than the national average, there is an excess supply of staffing that could be used to address surge need. This is dependent upon the assumption that we are currently meeting our medical staffing needs, which is highly unlikely for nurses. There are comparability issues of this region to the rest of the country, particularly in that Region VIII is a sparsely populated region. There may be economies of scale and geographic scope in urban areas of the country from which rural areas cannot benefit.

South Dakota, Utah and Wyoming average about 20 percent fewer physicians than the United States as a whole. The other three States in the region are at about the U.S. average (Figure 6). Emergency medicine and internal medicine physicians are arguably the most well trained to respond to a bioterrorist event. Figure 7 indicates that this region is at the national average for emergency physicians but is below the average for internal medicine physicians.

This region exceeds the national average in the availability of physician assistants and nurse practitioners. These professions may act as a substitute for physicians, particularly for North Dakota, South Dakota, and Wyoming, which are three of the most rural States in the country.

As a whole, this region has a number of nurses to serve the population similar to the rest of the country. Both North Dakota and South Dakota exceed the national average by 30 percent, although the number of nurses this represents is few since the population of these States is well under 1 million. Licensed practical nurses (LPNs) work side by side with Registered nurses (RNs), and their availability in the region is 20 percent less than the national average.

The skills of respiratory therapists will be useful in the event that the bio-agent affects the respiratory system. A partial list of agents that affects the respiratory system includes: plague, anthrax, and botulinum toxin. Other agents such as smallpox, hemorrhagic fevers, and ricin would require respiratory care as part of general supportive care. The resources in this region are close to the national average, where both North Dakota and South Dakota exceed the United States and the rest of the region.

Supplementary health professionals such as social workers, certified nurse assistants, and laboratory workers will also be necessary to respond during a surge event. Figure 13 demonstrates that the region is above the national average for social workers.

The region is slightly below the national average for clinical laboratory staff (Figure 14). Colorado, Montana, and Wyoming are below, while the other three States exceed the national average.

The region is slightly below the national average for certified nurse assistants as well (Figure 15). Colorado, Utah, and Wyoming fall short, while Montana, North Dakota, and South Dakota exceed the national average.

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HRSA Hospital Preparedness Survey Summary

A region may be able to collect State hospital preparedness survey results and examine them to understand particular regional capacities. Hospital infrastructure capacity and supply of relevant equipment was somewhat difficult to obtain via other sources. It was expected that some bioterrorism response relevant hospital infrastructure and equipment supplies could be determined through the HRSA Hospital Preparedness Surveys.1 In Federal Region VIII, we were interested in addressing regional hospital decontamination ability, negative pressure isolation room and personal protective equipment (PPE) availability. Members of the RMBT Working Group included representatives from each of the six State HRSA grantees. The RMBT Working Group collected all 6 needs assessments from the HRSA Hospital Preparedness Programs in the States represented by our region over the 1-year project period (Appendix E).

The survey instruments were examined to determine if there were common questions that would further contribute to profiling the region. Since the needs assessments were not required to be standardized across the States, all 50 States ask different questions and on different time schedules. In our region all six States distributed their surveys at different times; for example, Montana in September 2002, South Dakota in December 2002, and North Dakota in March 2003. Therefore, the data represent estimates roughly for the period of late 2002 to early 2003. There were varying numbers of questions (from 48-194) and the format varied with some States offering open-ended questions, requesting particular counts and asking for names of contact personnel.

As of October 14, 2003, results have been collected and compiled for five of the six States in our region: Colorado, Montana, South Dakota, Utah, and Wyoming. North Dakota is expected to provide their final data results in the near future. For this assessment we were only able to access partial data.

Table 3 outlines regional results in key topic areas where HRSA benchmarks have been developed (go to Chapter 5, Measures of Preparedness) including decontamination, personal protective equipment (PPE), and isolation.

1 In January 2002, all States were offered funding from HRSA based on population size to improve health care system preparedness. One of the critical requirements for the 2002-2003 grant year was to conduct a needs assessment of acute care hospitals and pre-hospital entities. Phase 2 would require implementation of a plan to address those needs. The HRSA grantees were given issue areas for the assessments: primary (vaccines, PPE, communications, drills) and secondary (personnel, training, patient transfer) priority planning areas with specific benchmarks.

Bioterrorism Response Planning

All hospitals in the region were asked if they had a specific plan for bioterrorism response (Figure 16). Collectively, 54 percent of hospitals in the region had a plan at the time the surveys were distributed. In Colorado, 100 percent of hospitals had a plan by 2002 as part of the State's requirement at that time.


Assessing the total amount of ventilators in Federal Region VIII is an important measure to estimate, particularly since many potential bioterrorist agents can affect the respiratory system. Figure 17 displays the number of ventilators in the region obtained from the HRSA surveys. Utah and Wyoming did not assess this in their surveys. The States that did address this question had issues in collecting an accurate count. For example, Colorado had too few facilities answer this question and feels its count does not accurately assess the status of the State. South Dakota had only one out of four regions answer this question, meaning its count is low as well. The regional total of ventilators available is a grossly low estimate of approximately 1,000 ventilators owned by hospitals in the region. It is important to note that many hospitals rent ventilator equipment and during a surge hospitals may be competing for this resource.

Equipment—Personal Protective Equipment (PPE)

The Occupational Safety and Health Administration (OSHA) requires the use of PPE to reduce employees' exposures to hazards in the health care workplace environment. Issues surrounding use of PPE are particularly relevant when examining readiness to respond to a bioterrorist or chemical event. PPE necessary for bioterrorist response includes face shields, safety glasses, gloves, masks, respirators, and protective suits; these come in many different variations of durability, cost, and ease of usability. There is still debate surrounding the establishment of guidelines for appropriate PPE for the different bioterrorist and chemical agents.

All States in our region asked if hospitals had the most basic form of PPE: N95 disposable masks. In Wyoming, the question was not as specific and was stated as: Do you have masks available such as N95? Approximately 65 percent of responding hospitals in the region had masks available (Figure 18).

Three States asked if hospitals had positive air purification respirators (PAPRs). They ranged from 15 percent of hospitals in South Dakota to 100 percent in Colorado (Table 3). Approximately 17 percent of the responding hospitals in half the States in our region had protective suits available (Table 3).


Decontamination issues were covered by all six surveys in very different manners. In Wyoming, 52 percent of hospitals had a plan for decontamination. This does not actually address whether or not they have the capability. In Colorado, 54 percent of hospitals could decontaminate a non-ambulatory victim (i.e., have a decontamination table/stretcher), 77 percent had external access to water for mass casualty decontamination, and each hospital had an average of one shower head per hospital for decontamination. Montana asked if hospitals could increase their capacity for decontamination and asked them to rate this need. Montana, North Dakota, and South Dakota asked hospitals if they had arrangements with outside agencies to provide decontamination services.

Only four States addressed the topic of decontamination similarly with one question of having this ability (Figure 19). North Dakota's data are still being compiled by an outside contractor and were not available for this topic at the time of this report. Montana, South Dakota, and Utah are similar in that over 1/3 of hospitals responding to their survey have decontamination capability. In addition, these States addressed the question in further detail by specifying if decontamination capability was internal or external, temporary or permanent (Table 3).


All six States asked hospitals if their facilities had negative airflow, isolation rooms (Figure 20). Over 54 percent of the region's hospitals that responded had this capability. In three States, an average of 28 percent of hospitals had isolation rooms specifically in the Emergency Department (Table 3).

Five States asked for the specific total number of negative pressure isolation rooms or beds in the facility (Figure 21). Montana and North Dakota have 163 isolation beds total. Colorado and Utah have 443 rooms total; this figure was multiplied by 1.5 to determine a bed estimate based on the assumption that each room has either 1 or 2 beds. This region as a whole has over 828 beds available in negative pressure isolation rooms.

Limitations Concerning Survey Data Comparison

There were several limitations in comparing the survey data across the six-State region. The major areas of concern include:

  • States in the region are at different levels of preparedness.

    All States in the region are at different levels of preparing and the tailored surveys reflect this fact. For example, Wyoming's survey was constructed to obtain information about level of planning of hospitals; it fell short of identifying specifics about the needs of hospitals to enhance preparedness. Hospitals were asked to assess their planning as complete, substantial progress, or incomplete in various topic areas.

  • Accuracy and reliability of survey data.

    Many States reported that the data may not accurately reflect needs in their respective States. Issues surrounding data accuracy included:

    • Respondents using "bed" and "room" interchangeably when delivering counts which would not reflect the true capacity for cohorting.
    • Low response rate from hospitals which would not reflect a true picture of need across the State if hospitals were self-selecting due to common issues.
    • Issues surrounding exposing State vulnerabilities if sharing data with outside sources in the region.

  • Are the data current?

    Initiatives for equipment increases are being funded and implemented at a faster rate than the data are being collected. Therefore, survey results on counts may be inaccurate due to new funding streams from HRSA and the Department of Homeland Security. For example, hospitals may now have PPE available through this year's equipment initiatives. Data represents estimates collected in late 2002-early 2003.

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